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} <br /> Please print or type.(Form designed fpr use on elite(12-pitch) pewriter.) <br /> t NONHAZARDOUS1•Generatofil)Number 2.Page 1 of 3.Emergency Response Phone 4.Waste Tracking Number <br /> WASTE MANIFEST CAL42"'013 1209-M-4we 037-111 A <br /> S.Generator's Name and Mailing Address Generator's Site Address(if different than mailing address) <br /> SXWM 1 LCO ICS.(SAFE'wwj <br /> t OM WEST SO tLTE RD <br /> TRACY,CA. 05877 <br /> Generators Phone: <br /> 6.Transporter 1 Company Name U.S.EPA ID Number <br /> SHOP F AJiD?.'a SCUTIOW,IW* Ci#�F�F34FiA�t <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> B.Designated Facility Nara and Site Address U.S.EPA ID Number <br /> W..IEP CEftC 57. Li�T)�1�:,1,11 AZ00E 013.57 ] <br /> PHMNK AZ M43 <br /> Facifity's Phone: 02-2n• ''� -r <br /> 9e• 9b.U.S.DOT Description(including Proper Shipping Nam,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit <br /> HM and Packing Group(t any)) No. Type Quantity Wt.Nol. <br /> 1- BATI ENES.VVET.FILLED ii TH lad.lWJ.F9,L04.774d5,8 i DF b Ft <br /> 2. LlthiitMrt BlitiftOWS,V.t !), 4 PAF;• P <br /> lineal Waste inwfat ixl. <br /> 3. faaderim ft,nort-D01'regititawF <br /> E4titnw,j4 l AJFfHm <br /> 4. <br /> 3.Special Handling Instructions and Additional Information <br /> �9-$4f4.Ais� !� 'F&i��.Fwd••.f..�f'rFUfYf�'fC►f���19�fi1a�. . <br /> 14. GENERATOR'S CERTIFICATION: I certify the materiels described above an this manifest are not subject to federal regulations for reporting proper disposal of t jezardous Waste. <br /> Cupar; s/0lferors Pdnlad/t'yped Name March Day Year <br /> � r <br /> --+ 15.International Sm <br /> pmerrts a <br /> Z ❑Import to U.S. ❑Export from U.S. ? Port of entrytaxit• <br /> Transporter signature(for exports only): Date leaving U.S.: <br /> fr 16.Transporter AclawMedgment of Receipt of Materials <br /> Transporter rfntedfryped n/1 <br /> Signature <br /> d y, ck1r, ev--m + Month Day Year <br /> QTransporter 2 Printecirryped Name Signal, Month Day Year <br /> 17.Discrepancy <br /> 17a.Discrepancy Indication Sparse Quantity Type ❑Residue ❑Partial Rejector ❑Full Rejectlon <br /> Manifest Reference Number: <br /> 17b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> U <br /> LL Factgs Phan: , <br /> W S7c.Signature ofAltemate Facility(or Generator) <br /> Month Day Year <br /> Z <br /> r� <br /> 1 B.Designated Facility Owner or Operator:Certification of receipt of materials covered by the manifest except as noted in Item 17a <br /> PrintediTyped Name Signature Month Day Year <br /> 6-NHM-C-C-11 <br />