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rn <br /> co C0 <br /> L0 N <br /> CD O <br /> O <br /> ry- <br /> n O <br /> O <br /> U <br /> O <br /> r <br /> Droved,OMS g No, a. <br /> -- <br /> 2 Page I of a.Emergeney fleslaMSU Phone 1.Willi � ? <br /> JA <br /> 2Af111i inti 1' <br /> 4, tL <br /> Wp�T MArdu fsi Dammlot's Silo Address lit dlaannl Ulan m oinq IddoM) <br /> s Donanse rdnlung Address WE6TF RN TRUGk1"tr4TLR <br /> vVE51 t1GK('EN7[R 3333S H*HVUAf99 <br /> FcOK•. a b7OCY.T0MI CA 95216 <br /> SILK- ,.A 96113 <br /> Genentula Ph— U.S.EPA ID Number <br /> S <br /> Transports 110"" ams <br /> U.S.EPA 10 Number <br /> 7.Tlnnaponar 2 Company Name <br /> US.EPA ID Number <br /> e,Dealgnelad Facility Nam and Saa AddraA <br /> PUTRERC,HILI:.LANUHI I INC. <br /> :Stf7UPUTRURO HILLS LANE <br /> SUISUN CA 945t3b re <br /> �l Faoill's Phono: 10.Carl.,.. I1.Total 12 Unit <br /> I <br /> ,Waste Shipping Niemand 0eacnption No. Type 0-111y, WI/Yat <br /> a.NOh1.HAZARCH H15 VrA461L 1 IQ 111,1 WAS I F i ER) <br /> Q r <br /> a <br /> 3 <br /> 13 Special Handling Insaucimns and Additional Inlomledon <br /> I p LY-16 b.... .:ny uaie 51e7efalBr <br /> t. <br /> 1 <br /> 11,GENERATOR'SIOFFEROR'S CERTIFICATION:I hereby declare that the coolenis of this coreignmenl are fully and atarauh`destlibetl above <br /> by Ina gultniPropeshipping name.and are Gassdied.packaged. <br /> marked and labeled,ple-ded,and are in all respects In pmPercondition for transport according to sonic. iniemailonal and national governmental regulations. Month Day Year <br /> Generator'vOlnror's Printer iyped Name Signature <br /> 15.Inearn idnai Shipments ❑Import 10 U.S. ❑Export from U.S. Pon of anby/exil'. <br /> Trans nets nature 0— rtsanl Data se-ca U.S: <br /> ¢ 16 iransponer ACXnowledgmenl of Receipt of Materials <br /> 2 iransponer I Pnn(ed(Fyped Name Signature Month Day Year <br /> � O + <br /> i Transporter 2 Pnmad,TyDad Name Signature Monty Day Year <br /> r <br /> 17.Discrepancy <br /> t7a.Discrepancy Indication Space ❑El Ouanlity, Type El Residue ❑Partial Rejection ❑Full Rejection <br /> � <br /> Mannesl Reference Number: <br /> f 17b Allemale Facility for Generator) U.S.EPA ID Number <br /> J <br /> u Facilie Phone: L <br /> m 17C.Signature of Alternate Facility for Generator) Month Day Year <br /> U z7 z <br /> LO O ° <br /> O w <br /> N M ° <br /> N <br /> Q 18.Designated Facility Owner or Operator:Certification of reof materials covered by the manifest except as noted in Item 17a <br /> U tz Ponled?yped Name Signature Month Day Year <br /> O <br /> C � <br /> O o <br /> 169.OLC-0 5 11977(Rev.9/09) GEN ERATOR'SISHIPPER'S INITIAL COPY <br /> N � <br /> U <br /> W F18801scrapanq <br /> O � ncy n FullRe�ecbonn Residue Radial Raiectlon W <br /> U O Indlcetlon Space D Qatimuty ❑Type = <br /> Z) > S W <br /> _ c Mart lest Relerence Number. rre al mi,er <br /> C � <br /> X00 0 <br /> � CY) N 0 U <br /> N = <br /> � � rn <br />