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f ' <br /> i <br /> -1 O16N%hAHDOUS 1.Generator ID Numb e R Ed 2.Page tol� 3.Emargeni 4.WasteTracMng Number �15��� <br /> WASTE MANIFEST - <br /> 5.Generators Name and Mailing Address Generators Site Address(II different than metiing address) <br /> SIM CIO Prlqs�LOS 361's"Y Ddw I <br /> IS <br /> Cava Snail Pira,WIO LOuiGleiT0,Rom M73,Haulbarr, TX M02 stoclaw,CA 1 <br /> Generators Phone <br /> 6.1mnsporter l Company Name U.S.FPA ID Number - <br /> ].Transporter 2 Company Name U.S.EPA ID Number <br /> 8.Designated FaclOty Name and Silo Address U.S.EPA ID Number <br /> rcmqmd I WHIM <br /> SM rxxM AU81h Rd. <br /> Factltiys Phone: MWOM-CA SOW 2MMAM - �r <br /> ea. is.U.S.DOT Description Qnduding Proper Shipping Name) 10.ConlNrrers 11.Total . 12UN1 <br /> Na RPe Quantity WINOI. i <br /> 1, <br /> t000pmMid-m Wadi SOM(SCA) <br /> w <br /> w 2 <br /> ooae i <br /> 3. <br /> u� <br /> -. 4. <br /> 13.8pecial Handling Instructions and Additional information <br /> RIPM,SAPIP 3W84 <br /> 3 8 I <br /> ' `Te 'C`ta£C? - 'Aar3 �. ` gD�lCii <br /> �>�°,��. ��6ira1�• 1�4�yl;r�r ; ss�� PFQ`rV)2-9 <br /> GH Q. <br /> A-0, * 71 -1-4 <br /> 14.GENERATOR'S CERTIFICATION:I certify the materials described above on this manifest are not sub)ec(to federal regulations for reporting proper disposal of Hazardous Waste. <br /> Ganenum'sl0tierors PrintedRyped Name SignatureMonth Day Year' <br /> an bwUH of sopm-i / 65 <br /> 3 r 15.International Shipments. ElImport to U.S. ❑EW It U.S. Psdyof.41 <br /> Ransporter Signature(for exports only): Date lea*g U.S.: <br /> w 16.1tansporter Aduwwfedgement of Receipt of Materials <br /> T n5 alar 1 Pinl ed N e Slg 1 re Monti Day Year <br /> ° Gly r12 1/1 <br /> W <br /> Transo0d65'2 Prime ed Name �SlQpelure D Month Day Year. <br /> o: <br /> r- 17.Discrepancy <br /> 17a Discrepancy Indication Space <br /> ❑Ouanllry, ❑type ❑Residue ❑partial Rejection ❑Full Rejection <br /> Manifest Refinance Number. <br /> 17b.Atiernate Facility(or Generator) U.S.EPA ID Number <br /> LLFacllftys Phone: <br /> - ❑ 17c.Signature of Alternate Facllily,(or Generator) jr Monti Day Year <br /> � w <br /> '$TSE <br /> 18.Designated Facility Owner or Operator.CerMica6mr of rec*of materials core red by the manifes l except as noted in llem 17a _ <br /> •Pinj , a e- SI n'eu Month Day Year <br /> g �C d 11 I l <br /> 169-8LC-0 5 11977(Fliev.9109) DESIGNATED FACILITY'S COPY <br />