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NON-HAZARDOUS t.Generator ID Number2.Page I of 3.Emergency Response Phone 4,Waste Trecking Nlanber _ <br /> WASTE MANIFEST %101 R OUTILD 3 d#10"Q23160ofl 0702871 <br /> I 5.Genembrs Name and Mat,ktg Address - Genemlor's Site Address(it different than malA address) <br /> Gte a4 Cort a 76 S;:^Je 1 14.15M <br /> CA. =Ifi 2MI W. ^►uNt Lr:TA goo Cr,-L CA SUIR <br /> I Generelor's Phare: <br /> 6.Transporter 1 Company Name <br /> Inc <br /> Arn=f.^.-..n t�::`l:^;;.°''�!",�c�.'X'1r.".'_'7. U.S.EPA ID Number <br /> ).Transporter 2 Company Name <br /> CH9cJRG1d�l,ik <br /> U.S.EPA ID Number <br /> 6.Designaled Fa6ty Name and Ske Address <br /> t+rG. .}Y c. Lao L�i1:1,eYYY.. U.S.EPA ID Number <br /> ' 1&::pbJ. if:.t.+vi,.:.i CADds^fiv4'3U1(► <br /> Fac4: s Phone: I.•.,'1fi iiC?.:.}�,t.A, �!! {#: ;jg„,.G;jx•R+',.jr� <br /> 9.Waste Shooing Name and Description 10.Containers 11.Total 12.Unit <br /> No. Type Quantity WINol. <br /> 1. <br /> ¢ 'T <br /> a h!:wFt rL t��a .:`Yr;Tea LoquA riIc <br /> = z. <br /> W <br /> c7 <br /> I <br /> 3. <br /> i <br /> 4. <br /> 13.Special Handing Instructions and Additional Information <br /> i 1"/!:'7(.V1Yw"GFik'J GS:LS.C1"Ikw"'tt 1";+„'a ,,w .ilii, YO111i f7T7 <br /> r PPtc-.r'- :C`. :7 &0-t fmv.jRi.mr_7 Mr-onb=(MI)423=,D(AIS <br /> 71[t 5-0.7 <br /> 1r, ' „ ) <br /> 14.GENERATORWOFFEAOR'S CERTIFICATION:I hereby declare that rite contents M tis consignment are fully and accurately described above by The proper sl"roping name.and are dassifsd.packaged. <br /> f <br /> marked <br /> and I1aob&&Plaacdarrdeedddand are b all respects in proper condition for transport according to applicable IMemalional and national governmental regulations. <br /> Gere HF; wo`I ti:11:»:!C:LNrii.T};'Of- �.i..:'�i.^I,'Rll'7d'1 Signature Month Day Year <br /> -t 15.IMemaOonai Shipments <br /> F ❑Import to V.S. ❑Export from U.S. Pot of entry/exit: <br /> Z Transporter Signature for exoods only): <br /> Dete leavi U.S.: <br /> ¢ 16.Transporter Ackrwwledgment of Roccipt of Materials <br /> O Transporter 1 PrkdedrTyped Nam Signature <br /> r r .a <br /> Month Day Year <br /> a t, 1 r �( _ t ![ I I <br /> a TranspoW 2 PdnTed/fyped Name Signalum - f - - MOMh Day Year <br /> f ~ <br /> 17.Msaepancy <br /> f 17a.Discrepancy Indication Space ❑Quantity ❑Type ❑Residue ❑Partial Rejection ❑Full Rejection <br /> i <br /> Manifest Reference Number. <br /> r T 17b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> V <br /> LL <br /> Facility's Phone: <br /> 17c.SignaWre o Alternate Facility(or Generator) Mann Day Year <br /> Z <br /> m <br /> W <br /> O <br /> 16.Designated Facility Owner or Operator.Certification of receipt of materials covered by the mani est except as noted in Item 17a <br /> Pdnted(fyped Name Signature Mach Day Year <br /> I <br /> 169-BLC-05 11977(Rev.9109) GENERATOR'S/SHIPPER'S INITIAL COPY <br />