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e C'" <br /> NON-HAZARDOUS 1 Generator ID Number 2 Page i of 3 Emergency Response Phone 4 Weste Trecking Number <br /> F" 'I ` 1 tG}GWASTE MANIFEST s .F <br /> +'•1'- -«+ !_L.t=J <br /> G to SSrcIta Iess rf Brent Than maifio aQOree { <br /> S.GepiL(grisC "^i$hdfr "t�,9n` 59;1 l61 Rt3r�' f11 (.drAA r. .�F9_"�(47�x.t..„F�xdY <br /> t T�7CkFif++ h' 1+1' dill :2?'3 5400PAt1FI',AVENLIF: <br /> `TOi:{':-t't-N CA $t'-_ ill �i <br /> Generators Phone: <br /> 6.Transposer i Com an Name U.S.EPA 10 Number ry •� <br /> 4'vF +_ 1.:.^r'dP.lP71 -i:JT;:',L'i f * iC:E; IN,C. :., cs. 4? ii Ci U C! t, 'I 1 r1 <br /> ' 7.Transporter 2 Company Name U.S.EPA ID Number <br /> ' B.Oesignat�d FociIl,NNarp,a�deq{(ddrass U.S.EPA ID Number <br /> 31375 POTRERO HILL LLkI':iw <br /> SUI UN CITY C:'. L-4'S5r5 <br /> 7i�'i 43:i•4d3 <br /> ' Facifi s Plane: - <br /> 10.Containers 11.Total 12.Unit 1 <br /> 9.Waste Shipping Name and Description <br /> No. Type Quantity WTNoI. <br /> G is I C'10 <br /> w <br /> z 2. <br /> w <br /> ' ) <br /> 3. , <br /> I I <br /> 4. it <br /> ' 13.Special Handling Instructions and Additional Information <br /> lfE:7+-[? .A.P•4:'F?�>FF.:i^>r, e:, l��!a.�t1i:+'�.LI 1x!?�".`,rI?s.�M.J� L,�i,i?:kz;•TSEr"C rRc73�?'r'.+`fc,u4'7 YI AF+:•t'Li';?:. L'.[LI. 3.�-rt'�,w a <br /> ! ,.•D1S:zt1�?"F1Pi3,:C31; •ti's?t3 s,z;Pr'aLIG't'�+,�:rt'1', ilii _ 31.60 GQLQ <br /> CR 2 <br /> Yw^):'Et i+i.t>D 3M.`:;i:�:%, 6i�s:ii.t7t^,F7 iYrfr. 11305 k'�'f .47'f .ot';'bT7' :dYiAG1 P .r r.':=n "d MP(1.i (f' w -a- <br /> 14. <br /> 14.GENERATOR'S/OFFEROR'S CERTIFICATION:I hereby declare that the contents of this consignment are fully and accurately described above by the proper shipping name,and are classified,packaged, <br /> ' marked and labeled/placarded,and are in all respects in proper condition for transport according to applicable international and national governmental regulations. <br /> Genandoes/OHerors Printedrryped Name Signature _ �•,^a. r,•._..- Month Day Year <br /> ' F 15.International Shipments•• ❑Import to U.S. ❑Export from U.S. Port of entry/exit: <br /> z <br /> Transporter Signature for exports only): Date leaving U.S.: <br /> m 16.Transporter Acknowledgment of Receipt of Materials <br /> Transporter 1 pnled/Typetl Name Signalbre 1 /' Month Day Year <br /> ' ° J '8 iii (4. _ kv1.K `i� C ale,.�2 • Ci .3 5 is <br /> Transporter 2 Printed/Typed Name (7 Signatifne •f Month Day Year <br /> r <br /> 17.Discrepancy <br /> 17a.Discrepancy Indication Spam El Quantity Type ❑Residue ❑Partial Rejection ❑Full Refection <br /> ' Manifest Reference Number. <br /> 17b.AI emate Facility(or Generator) U.S.EPA ID Number <br /> J <br /> U <br /> rai Facility's Phone: <br /> w 17c.Signature of Alternate Facility(or Generator) _ Month Day Year <br /> a <br /> z <br /> w <br /> 18.Designated Facility Owner or Operator.Certification of receipt of materials covered by the manifest except as noted in IIeT57a <br /> Printed/Typed NarRe/ Signature " . -�_ Mjjolth /Ay q �ear <br /> '169-BLC-0 6 10498(Rev.9109) �f TRANSPORTER#2 <br /> i <br />