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DESIGNATED FACILITY TO GENERATOR <br />NONHAZARDOUS I. Generator iD Number _ <br />WASTE MANIFEST q 2a o o 2S 76 <br />2. Page 1 of <br />( <br />3. Emergency Response Phone <br />707 71V 2.075' <br />4. Waste Tracking Number <br />0Y1 b 13 <br />b. Generator's Name and Mathrg Address, n Generator's Site Address (if different than mailing address) <br />J ( K E v, ro men-fal Inc, <br />7,5'S-7 Kr►+1c10 ox. VS . <br />7ro„c�y, , Ca• 9530"1 <br />Generators Phone: 9_51 536 3Y4H <br />6. Transporter 1 Company Name <br />U.S. EPA ID Number <br />J if R Environ Inc. <br />Co�20o0�03l0 <br />7ansporter 2 Company Name <br />U.S. EPA ID Number <br />B Desgnaled Facility Name and Site Address VI'5 l'an5 Pe. i ref G C Y ► nj C. <br />US EPA ID Number <br />YySri k,,17,e-- oL ve-, <br />Mc Clcllan, CC_ gS65;L <br />FaaiiN's Phone: 111, t;V Tim <br />9. Waste Shipping Name and Description 10. Containers <br />11. Total 12. Unit <br />No. Type <br />ouant y WUvol. <br />' 6xC lU G CCYG <br />46C <br />s <br />�ArE x AutvT <br />F <br />4; 906 <br />P <br />W <br />2 Exclude of Rccyc.le.ble MA4,r,,',1 <br />LA TEX PASrvT <br />(w;000 <br />P <br />3 <br />13 Special Handling Instructions and Additional Information <br />6X CFD <br />14. GENERATOR'SIOFFEROR'S CERTIFICATION: I herety declare that the contents of this consignment are fully and accurately descnbed above try ft proper stooping name and are dassi6ed, packaged. <br />marked and 1abe:ed Placarded, and are in all respects in proper CXdt)On for transport according to applicable Intemabonal and rational govemmenial regulations. <br />Ge rators,Ofleror s Printed?yped NameSignature <br />J oS2 1. S{ I Vita <br />Month Day Year <br />Gy <br />z <br />15, Intermborutl Shipments <br />❑ Import to U S. ❑ Export from U.S. Pon of entrylexit: <br />— <br />_ Transporter Signature (for expors only) Date leaylno U.S.: <br />4¢ <br />16. Transporter Aduawledgmeni of Receipt of Materials <br />o <br />Transporter 1 PrintediTyped Name S Nr <br />� <br />Josv s, SII✓� <br />Month Day Year <br />En <br />Z <br />Transporter 2 P nledTyped kame Signature <br />to t3 <br />Month Day Year <br />f- <br />17. Discrepancy <br />17a. Discrepancy Indication Space <br />❑ Quantity ❑ Type ❑ Res due <br />❑ Partial Rejection <br />❑ Full Refection <br />Manifest Reference Number. <br />I7b. Alternate Faatity (es Generates) <br />U.S. EPA ID Number <br />J <br />U <br />ua. <br />Facility's Phone: <br />w <br />17c. Signature of Aftemate Facility (or Generator) <br />F- <br />MonLn Day Year <br />N <br />W <br />O <br />18. Designated Factdy Purer or operator. Certification of receipt of materials covered by the mangiest except as noted in hem 17a <br />PnntedTY\ <br />lName^ N , \ <br />Month Day Year <br />1R0_RI n_n a 4nnne m_.. .. r—, <br />DESIGNATED FACILITY TO GENERATOR <br />