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". t"ay.'rv'7 DESIGNATED FACILITY TO dEff FMT'OFi <br />NON -HAZARDOUS <br />I Generator ID NumCe <br />2. Page 1 of <br />1 <br />13, Emergency Response Phone <br />4. Waste Tracking Number <br />WASTE MANIFEST <br />iCZ f l t< �;? S7 <br />J_9Sl 7 29&L� <br />5. Generators Name and Alailmg Address r Generator's Site Address (If different than mailing address) <br />v,'rOAm C -n rz"- <br />7557 Car(Y <br />�loc �i(/} 95 L/ <br />Generators Ptwne: S i <br />9 <br />6. Transporter 1 Company Name <br />U.S. EPA ID Number <br />L ' � /J "_2�G1 ,`f <br />� r 7� <br />7. Transporter 2 Ccmpany Name <br />f"DODo�ci•S-2 <br />U.S. EPA ID Number <br />B. Desgnat€d Facihy Name,,,and Site Address <br />Cal:4orntc� ()�r�7 1�CL�CIt� oc . <br />U.S. EPA ID Number <br />a Le-I'C''i- Dr. $Sa <br />Sd cyc�rvt C n fO i C 4 q 583 8 <br />, 'S Phone: <br />racl <br />9. VJaste Shipping Name and Description <br />10. Containers <br />11. Total <br />12. Unit <br />No. <br />Type <br />Quantity <br />WUVol. <br />'zf Cclv�ec �cycic�bl� Ma�e`la, <br />L <br />Ci- <br />©aV <br />W <br />2. <br />3. <br />4. <br />13, Special Handling Instructors and Additional Information <br />14. GENERATOR'S(OFFEROR'S CERTIFICATION: I he eby declare that the cements of this consgrtmenl are ILAy and accurately described above <br />marked and labeled'p'acarded, and are in al respects m p•oper cond,ton for transport accordvg to applica:,'le <br />. packay^ed. <br />by the proper stupgng name!%Mrorgh <br />intemahwi and national governmental <br />Generater's'Offerors PrintebTyped Name S azure <br />regulations. <br />Oaml, R i C It r ` <br />Day Year <br />J <br />z <br />15. International Stnpments <br />❑ Import to U.S. ❑ Export from U.S. Port <br />of entrylex4: <br />Trar rter St alio- Ifor ex rts on Date leav U.S <br />it <br />16. Transporter Acknowledgment of Receipt of Materials <br />n <br />Traer 1 PnntedlTyped Name Signature <br />(/O�//r�/ 1L420 IiC <br />Idomh year <br />l /7 <br />/Day <br />/ �3 <br />Q <br />Transponor 2 PdntecVTyped Name Sir lure <br />Monty Day Year <br />F <br />17. Disaepancy <br />17a. Discrepancy Indication Space <br />❑ OuarSty ❑ Type ❑ Resd.re <br />❑ Partal Rejection ❑ <br />Full Rejection <br />Manifest Reference Number. <br />� <br />17b. Alternate FaciFry, (or Generates) <br />J <br />U.S. EPA ID Number <br />U <br />ua <br />Factity's Phone: <br />Signature of Alternate Facility (or Generator) <br />Q17c. <br />Month Day Year <br />z <br />2 <br />w <br />0 <br />18 Desgnwed F lift' Orrner or Operator Certification of receipt of materals covered by the nantest except as noteeO in Item 17a <br />Print Na VL r' Signahlr� <br />x • I <br />� Monfn Day Year <br />IJ <br />". t"ay.'rv'7 DESIGNATED FACILITY TO dEff FMT'OFi <br />