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-00 <br /> i NON-HAZARDOUS 1.Generator ID Number 2,Page 1 m 3.Emergency Response Phone 4.Waste Tracking Number• <br /> a� (800)Q44,100 24286" .01 <br /> WASTE MANIFEST f <br /> i=r n Generator's Site Address different than mailing address) <br /> sy+�ensrafor's�}ame,and Malin ss <br /> r: l lJC�l1+11 kjT1JtY01}tT1t?f11G11 M311i3 f�Crt' 1't31:t7. C{1{ifffi(xrl � <br /> t � x3 Pacific �tavFr > , <br /> RD,Box 000A Stockton,CA <br /> (#`er:elato sP orale`G/4 945H (877)386-60411 <br /> U.S.EPA UD Number <br /> 8,Transporter 1 Company Name Ne , <br /> 0ELSI-IIRt <br /> :. w <br /> 7.�q1Z.210ompftC118�r39 U.S� IDZmber0lt me J11{ <br /> 8.Designated Fadity Name and Site Address U.87EPA- Number <br /> CailSafit~!' . <br /> 12828 1*Ilbiscur,Ave <br /> Mol;aCtt1}. CA ti�3 01 <br /> FacfM es Phone: <br /> 10.Canlaineis 11.Total 12.Uhtt <br /> 9.Waste Shipping Name-and Das r101Dn No. . Type cmanrtty Wtivol. <br /> a 1 {+}w,i1-L'?G"1"I�et71a17Lr'd Mrd:�rial (Solt Contaminh ted with ��//��))/� !• Orn <br /> jf <br /> In <br /> Fetid r-trrl Prt}r�urAs, 110fI-ha7 ji�lous NNN .�� l <br /> � 7 <br /> CD <br /> 3. <br /> r <br /> 0 4. <br /> rw ,� �s(r 5� xt krrTS5 <br /> •w.��.''�'f"T' (..✓ICJ r Y. ���.+M.ek3� ,��� <br /> 13,$We]Handng lnsbucllons and AddilbW Infomwtion CEMC Cftd: ,Aj exis Rr.-cher <br /> '91-1"w tNvF_-anevirlohl (CMILL CU'VI'lNCIu i BE:Sl:24'28(37• BUSS EF UNI r: MB.1),. <br /> JLI E'-RG: N/A 1 I'i 10; r 8)971 <br /> orsl Y(W ; 70 Utalkeci 1111 yr?rtI <br /> %ASVI LEVrl_ D PPE 8,SPLASHF'l�OTECTION (1t=/�PPLIC.Rk�L15) t�kt�t ILh't�. <br /> 14.GENERATOR'SIOFFEROR'S CERTIFICATION:I hereby'declare that the cordente of this conslgnment.ere fuly and acourately desewd above by the proper shipping 9,and are dagsllled,"god, .•; <br /> marked and labeledlplacarded,and are In all respects In proper condition for Imnsport acooiding to applicable'Intemattonalr Moral governmental regulations. <br /> GeneratoralOBeror's Pdntedrfyped Name Signature Da F� Ye}'. <br /> Larty ontl°tc:t-i:of�3F 4,1 {}rr behalf of generator w. I a <br /> ` 1b,International Shipments ❑Import to.U.S. Export from.U.S. Port of entrylexlt: <br /> Tran er Skmature for exports Date leavina U.S.: ` <br /> 18,TmngMer AdmoMAmm t of'Rensipt d Mat8dPb I ' <br /> Transporter 1 P ed N me Signature ! _ Day Yea <br /> Transporter PdntedrTypodNo d Signature. Day Year <br /> 17.Mmpency <br /> 17a,Discrepancy Indlcallon Space 1:1 Quantity a rp, E'ReskJue ❑Partlel Re1edlon ❑Ful1:Re*Pn, <br /> Man"Referenbe Number, <br /> r 17b,Alternate Facility(or Generator) -U.S.EPA ID Number <br /> k Faditys Phone: <br /> 17o,SIgnalure of A@emale Fao ft(or Generator) Month Day Year <br /> 18,D Igt to Fahy Ovrner or Ope 6r Ceiigicafion of receipt of materials covered by the manifest exxcepl - <br /> -- --——-- as.rroted <br /> Prkded/lyped N me Signature _ � Day y <br /> TRANSPORTER#1 <br /> 168-BLGO�10498(Rev.9/09) "� .. <br />