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y 1► <br />NON -HAZARDOUS 1 Generator ID Number 2 Fac= + cf 13 Emergency Response Phone 4. Waste Tracking Number <br />WASTE MANIFEST A K 00 09-� S" j 6 i ?03 71q �O qS- V D -9 13 <br />5 ue'crat r s Name and Maihrg Aedress., T �,►V rOh l�►�' (d`� ��► G . '_reratcr's SAe Aod:ess (if dNerent than rw ling a6ores5l <br />'1557 Cw�rncl� ti�� <br />�t -53a rgly T`acy , Cts. gS3ar( <br />u= 2rators Pbor <br />- ---spc^er 1 Company Name U.S. EPA ID Numlter <br />J f V— En n r c. CAP -000 -0310 <br />r7. Trans_t'e• I C:-c3oy Name U S. EPA ID Number <br />_as ;-a:eo Facility Name and Site Acaress . i U S. EPA ID Number <br />lei St at,s s.-�n KecyClt n�, ..enc. <br />//�'sYt4'hA' gyral 1c,t-17r r ave <br />ablitvqi� 1'16 C1e- j1 j1, C&., 9565z <br />711 a^a rombonal mromranon <br />3,X Cyd <br />q.� `ix t M(tts <br />13. GENERATOR'SIOFFEROR-S CERTIFICATION; I hereby declare that the contents of this consgvnem are fully and acourak* oescnoed above by :he prCter sh,opmg name. and are dasshed. packagea <br />Tanked and labeled'ptacarded. and are in all respects in proper conation fcr transport acro dmg to appiicable intemabonal and nal onal govorr9wal regulations <br />Generators,Olferor's PrinledTyped Name <br />g. Waste Shipping Name and Descnpticn <br />10. Containers <br />t t. Total <br />Quanity <br />12. Una <br />1'lt.Nol <br />pM�onth <br />IV <br />113 <br />No <br />Type <br />Lat�cx <br />of entryrexit: <br />C F <br />M o o- <br />Data lea. q U.S.: <br />cc 16. Transporter Ackn edgment of Receipt of Materials <br />2.Excl�drd r-ccycla.b ?/ A4Aftr,'0L-j <br />Transporter 1 PnntedrTyed Name <br />Op <br />Sgnature <br />Mcnth Day Year <br />N <br />3. <br />a Transporter 2 Pr rated l yped Name <br />Signature <br />Momn Day Year <br />17. Discrepancy <br />i <br />17a. Discrepancy Indicabon Space <br />❑ Quantity <br />❑Type ❑ Resdue ❑ Part;al Rejection <br />711 a^a rombonal mromranon <br />3,X Cyd <br />q.� `ix t M(tts <br />13. GENERATOR'SIOFFEROR-S CERTIFICATION; I hereby declare that the contents of this consgvnem are fully and acourak* oescnoed above by :he prCter sh,opmg name. and are dasshed. packagea <br />Tanked and labeled'ptacarded. and are in all respects in proper conation fcr transport acro dmg to appiicable intemabonal and nal onal govorr9wal regulations <br />Generators,Olferor's PrinledTyped Name <br />Sgaatu <br />Day Year <br />..6 V. SilV� <br />pM�onth <br />IV <br />113 <br />15. International Shipments <br />t- ❑ Import to U.S. <br />❑ Export from A. Port <br />of entryrexit: <br />— T sporter Sgiature for exports <br />Data lea. q U.S.: <br />cc 16. Transporter Ackn edgment of Receipt of Materials <br />Transporter 1 PnntedrTyed Name <br />Op <br />Sgnature <br />Mcnth Day Year <br />N <br />a Transporter 2 Pr rated l yped Name <br />Signature <br />Momn Day Year <br />17. Discrepancy <br />17a. Discrepancy Indicabon Space <br />❑ Quantity <br />❑Type ❑ Resdue ❑ Part;al Rejection <br />❑ Full Rejection <br />Man,!est Reference Number. <br />t1 TD, Alternate Facility (or Generator) <br />J <br />U.S. EPA ID Number <br />U <br />tai Facility's Phone: <br />w 17c. Signature of Altemate Facility (or Generator) <br />Month Day Year <br />Q <br />Z <br />t7 <br />W <br />D <br />1& Oesl(g1ed Faakry Ovmer or Operator. Cem5cabon of receV of matenals cohered by the manifest except as now Item 17a <br />Prnte&T Namwr (� re Month Day Year <br />169 Bic -o 6 10498 (Rev. 9/09) DESIGNATED FACILI TO GENERATOR <br />