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NON-HAZARDOUS 1.Generator iD Number 2.Page 1 of 3.Emergency Response Phone 4.Waste Tracking Number x <br /> WASTE MANIFEST p iaf W 1' ,I <br /> S Generator's,Name and Mailing Address.i - t 1t4r..F1'7 Generator's Site Address(if different than malling address) <br /> '� :•1 <br /> ,.l•,I`r <br /> E t'tt tFa, SUTE EMU Pie4irtf`t\`r'ENVP: <br /> ;.'M"7;'(:IG-J C.,.'t ._,:01 <br /> Generator's Phone, n.•rU_,dfdi <br /> 6.Transporter 1 Company Name U.S.EPA ID Number <br /> 1+R4—, Elgvis oNji EfVf'-J_SE VI.r .'.s INC, a;- p, f}, 0 . C, tit s IJ 9 'i .d <br /> 7.Transporter 2 Company Name - U.S.EPA ID Number <br /> 8.Designated Facility Name and Site Address U.S.EPA ID Number <br /> F'OT11'RP- O t-„I,(S t.nNDALL. <br /> W-46 POTRERO HILL LAW,-- <br /> Sl,IfE4.tM CITY C'A WS-5 <br /> Facili(a Phone: 7117 -0'3..T1Rfi6 <br /> 9.Waste Shipping Name and Description 10.Containers 11.Total 12.Unit <br /> .No. Type Quantity WWot. <br /> ¢ <br /> "NON1 F,KF2UGii a a SQUO(SOL- t1T'r? <br /> 0 db6��r� <br /> G l in1..7i..`..f1H'uL1G�aj <br /> w 2. <br /> FI <br /> 3. ki <br /> 1 <br /> 4, <br /> 13 Special Handling Instructions and Additional Information ,', <br /> €TCan. A PPl'ti4 R}n!Ipc, I?rnR uAL °r,•i7C"t'rU,,:ivr;; 1w00.1P ft±199 JC; .jZ;nwr; e 111-G 11 Pt.!} '",tr"`?`r R i!�H° 13} rrF: <br /> C 014 a110'.Fu11' CvI:,'0:Out t_O'.iatUvi.tt3J?n 11'dr:- :i 160 C"ji,n 4+'3tLL7v Gri:f.vE, q imc,14u o F"atfi:Ht} <br /> r:� cl:7'i4 "hit <br /> 1114✓~° 1,750:• E'EPiR-y polar. k'raftu)?5 , ' iS E;43 i1, f .•.�� hx1l �n <br /> . t l r„ �✓awl <br /> 14.GENERATOR'S)OFFEROR'S CERTIFICATION,1 hereby declare that the contents&I this consignment are fully and accurately described above by the proper shipping name,and are classified,packaged, <br /> marked and Iabeledlpiacarded,and are in all respects in proper condition for transport according to applicable international and national governmental regulations. <br /> Generator'slOfferor's Printed/Typed Name Signature,.. Month Day Year 'y <br /> 5,A <br /> F-t <br /> 15.Infemetional Shipments Elimport to U.S. El Export from U.S. �- �- Pod of entrylexit: <br /> z <br /> Transporter Signature for exports only): Date leaving U.S.: <br /> w 16 Transporter Acknowledgment of Receipt of Materials <br /> F- Tra spoiler 1 P'ted(ryped Name Signature Month Day Year <br /> � � G00 C <br /> N ..c <br /> a Transporter 2 Pdnted?yped Name SigneNrev Month Day Year <br /> t ¢ <br /> F <br /> 17.Discrepancy <br /> •' 17a.Discrepancy Indication Space ❑ i <br /> Quantity ❑-Type ❑ ❑ ❑ <br /> Residue Partial Rejection Full Rejection <br /> J <br /> 'a Manifest Reference Number. <br /> F 17b.ANCmater Facility(or Generator) U.S.EPA ID Number <br /> J F'„ <br /> U <br /> ua. Faciliys Phone: <br /> w 17c.Signature of Altemate Facility(or Generator) Month Day Year <br /> z <br /> (7 <br /> a <br /> !t <br /> 18.Designated Facility Owns)ogOperator.Certification of receipt of materials covered by the manifest except as noted in Item 17a j <br /> Prtntedfryped Name J( 1), Signature }4 (f Month Day f r <br /> f k:f <br /> 169-BLC-0 6 10498(Rev.9/09) ' TRANSPORTER $2 <br />