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__._———— _—___ _.- ——�——_.__—— .———-- <br /> NON-HAZARDOUS <br /> -NONHAZARDOUS 1.Generator ID Number 2.Page 1 of 1 3.Emergency Response Phone 14,11aste Tracking Number f <br /> WASTE MANIFEST NOT REQUIRED 1 213801 <br /> S.Generalors Name and Malting Address Generators Site Address Ill different than mailing address) <br /> �'E JV cls CC A,ft. Oly�n JV <br /> 7ti HOM Sftd,Stift A En1WyWft,CA 946M 1022 Fivintage,Rd,Rtan,CA MIX ) <br /> Generalor's Phone I <br /> 6.Transporter 1 Company Name U.S.EPA Ib Number <br /> AmerIallm Intearded Servilm, I . CAR 0148M <br /> T Transporler 2 Company Name U.S.EPA ID Number <br /> 8.De eNoTbuaw. <br /> ss U.S.EPA ICS Number <br /> 1830 W.ift Stred CAD028409010 <br /> FaciRy's Phone: Uma BeachCA.9W13 5U-432-SM <br /> ga. 9b.U.S.DOT Description(including Proper Shipping Name) 10.Containers 11•Tvtal 12.Unit <br /> No Typo Quantity Wt.Nol. <br /> 1. . <br /> o NON CST REGlLA7E#?MATERIAL(QECON WATER) q Gjz <br /> I <br /> jz <br /> .-L <br /> w 2. <br /> 3. <br /> 4. <br /> 1 <br /> 13.Special Handling Instructions and Additional Information CRA r <br /> Wow eqAvow . WeWft or vokmm xe <br /> as �►�(OW) a-r via I <br /> 107 <br /> 14,GENERATOR'S CERTIFICATION:I certify the materials described above on this manifest are not subject to federal regulations for reporting proper disposal of Hazardous Waste. <br /> GencralorslOfferoes Prinledflyped Name <br /> Signature Month Day Year <br /> {{ <br /> 1$.lnlornntional Shipments ��--yy " ) f t <br /> IJ fmpert to U.S. ❑Exporf from U,S. i Partfof entWexlt: <br /> Transporter Sfgnalure(tor exports only): Dale leaving U.S.: <br /> LU 161ransporter Acknowledgement of Receipt of Materials a <br /> 0 <br /> Transport 1,PrinteFlFyped Name Signature Month Day Year ) <br /> 0. t- lv(s <br /> "trans or2$dnte"pedName Monh f3sy Year I <br /> F- <br /> 17.Oisraepancy f <br /> 17a Discrepancy Indication Space ❑Quantity ❑Type ❑Residue ElPartial Rejection <br /> ❑Full Rejection 1 <br /> I <br /> Manifest Reference Number: I <br /> 17b.Alternate Facility(or Generator) U.S.EPA 1D Number <br /> J I <br /> I <br /> U <br /> LL Facit' s Phone: <br /> w 17c.Signature of Alternate Facility(or Generator) Month Day Year <br /> r5 <br /> m <br /> 0 <br /> I <br /> 18.Desgnaled Facility Owner or Operator:Cerlification of receipt of materials covered by the manifest except as noted in Item 17a <br /> Printed/Typed Name Signature Month Day Year <br /> 169-BLC-0 5 11977(Rev.9109) GENERATOR'S/SHIPPER'S INITIAL.COPY <br />