Laserfiche WebLink
NON-HAZARDOUS 1.Generator ID Number 2.Page 1 of 3.Emergency Response Phone 4.Wasite tracking Number 213803 <br /> WASTE]MANIFEST p 1} C <br /> 5.Generatoes Name and Mailing Address Generator's Site Address(if different than mailing address) <br /> 011014ftn,'V CIO GRA,Inc, Ovirow,Iv <br /> 5900 HoNa Skeet SURB A Effwydb,CA 946M 1 022 FMrdW Rd,Rte,CA MW ' <br /> Generator's Phone <br /> 6.Transporter 1 Company Name U.S.EPA ID Number <br /> sm1oft CARO00148= �. <br /> 7.Transpiter 2 Company Name U.S.EPA ID Number <br /> 8.Da,T'Ignated iblyLJaml�and Slue lev U.S.EPA ID Number <br /> LwXW <br /> 9M&AttU Rd CA09WM133 I! <br /> Facility's Phone: Mot=,CA I <br /> ifl.Containers 11.Total 12.Unit <br /> 9a. 9b.U.S.DOT Description(including Proper Shipping Name) No Type Quantity WIN& <br /> 0 1. N0N4)OT RE�aMATED MATERIAL(NON-HAZARDOUS CM Y <br /> d <br /> wIL) C�' t t <br /> a <br /> W 2. I <br /> 3. <br /> I <br /> 4. <br /> 13.Special Handling Insbuctions aad Addilional Information f CRA KV <br /> Wew pr&3at vc e*#fflWd 1MWa Mob or voklam i <br /> ,�I _ t1o1 1-3 CIS 4 <br /> 1 <br /> nab <br /> Charr*= piala*: 1 OW � <br /> 14.GENERATOR'S CERTTICATION:l certify the materials described above on this manHesl are not subject to federal regulations for repurling proper disposal of Hazardous Waste. <br /> Generatofel0fieror•s PrintoWlyped Name Signature Month Day Year <br /> lo IJ1 <br /> -i 15,Tn�ernakianal Shipments ❑ ' � f <br /> p_ Import to U.S. ❑Export from U.S. Purl of eniryle it: <br /> z Transporter Signature(tor exports only): Date leaving U.S.: <br /> � 16.TransporterAcknavledgementofnecoiptofMatecials 1 <br /> W <br /> Transporter 1 Pri <br /> nted/Typed Name SignatureMonthonih Day Year <br /> cc <br /> fJ I <br /> -'L If —411 h c) <br /> Transporter 2 Printedflyped Name Signature IAA th Day Year <br /> F <br /> 17.Discrepancy <br /> 17a Discrepancy Indication Space ❑Quantity ❑Type ❑ t <br /> El Partial Rejection Full Rejection <br /> Manifest Reference Number: <br /> 17b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> Faclli s Phone: <br /> 17c.Signature of Aitamate Facility(or Generator) Month pay Year <br /> W <br /> Z <br /> W <br /> D <br /> 18.Designated Facility Owner or Operator:Certilioation of receipl of materials covered by the manifest except as noted In Item 17a <br /> PrinledlTyped Name Signature Month Day Year <br /> 169-BLC-0 5 11977(Rev.9109) GENERATOR'S/SHIPPER'S INITIAL COPY <br />