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t, <br /> NON•NA7ARDOUS 1.Generator ID Number 2.Page 1 of 3.Emergency Response Phone 4.Waste Tracking'Number <br /> WASTE MANIFEST NOT APP140ABLE / 7 r7 7 - ?r fi-S 7 5 SS 172403 <br /> 5.Generatars Name and Mailing Address Generators Site Address(ti different Item malli address) <br /> C, �. ....�a�;tortn�c� Q r c.i: te_ Ya . J <br /> S4rveJ ,Svt ¢ r I IC,tl5 Cit. <br /> traYo�SPria'frl''! `1 c _ C r <br /> 6,.1mnsporter 1 Company Name U.S.EPA ID Number <br /> ?10T APPUCASM <br /> 7.Transporter 2 Company Narne U.S. <br /> Wt <br /> ID�Nuusmbeerlt��ripp <br /> sr, lMrWf tF;1'P�.�ABLE { <br /> 8.[Jeaignated Facltlty Name and'SNe Address U.S.EPA ID Number I <br /> RECMGY HAY ROM M I`iKi'1',AIP�$ <br /> WS HAY`ROW^VAMUE,CA am <br /> _ <br /> FaclWs e: <br /> 9.Waste Shipping New and Description 10,Containers 11.Total 12.Unit <br /> No. Type Quantity WINol. c:1 <br /> 2: <br /> l: <br /> S c <br /> 4 <br /> 4 <br /> 13.5pec al Handling Instructions and Additional Intormu>� <br /> 14.GENERATOR'SIDFFEROR'S CER71KCA710Ni I hereby declare that the oonlents.of this eonslgnmem are fully and accurately described above by the proper shipping name,and are classified,packaged, <br /> marked and IabelWoocarded,and are in d respects in proper condition for transport according to applicable international and national governmental regulations. <br /> Generator's/Offerors Printed/Typed Name Signature Month Day YearCL <br /> . <br /> 16.In smational Shl pts <br /> ❑ <br /> Import to U.S. Expert from U.S. Part of entry/ex t <br /> Transporter Si nalUre for exports only): Date Wvin U.S.: <br /> cc 16.Transporter Acimowiedgment of Receipt of Materials <br /> uj <br /> Transporter 1 Printedliyped Name Signature /r Month Dei/ Year <br /> y / ! <br /> r <br /> 4 Transporter 2 PrintedRyped Name Signature Month Day Year <br /> 17.Discrepancy <br /> 179,Discrepancy Indication Space Quantity ❑Type 0 Residue ❑Per&t Relecilan ❑FW Rejection <br /> Manifest Reference Number. <br /> 17b.Alternate Facility(or Generator) U.S.EPA ID Number. <br /> U <br /> ua Facliks,Phone: <br /> w 17c.Signature of Alternate Facility(or Generator) Month Day Year <br /> F ' <br /> z <br /> 'C7 <br /> ru _ <br /> 0 <br /> 16.Deslgnalsd Facility Owner or Operator.Codification of receipt of materiels covered by the manifest except as noted In fir 17a <br /> PntedfTyped Name ggaature Month Day Year <br /> 169-BLS-C 5 11979(Rev.9/09) GENERATOR'S/SHIPPER'S INITIAL.COPY I <br /> I <br />