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NONHAZARDOUS 1•Generator ID Number 2.Page 1 of 3.Emergency Response Phone 4.Waste Tracking Number <br /> WASTE MANIFEST _ <br /> 5.Generator's Name and Mairing Address GenereioP€rft?A rocs(i ddferent than mailing address`)" 0 <br /> OALLLAMJOHM MAT8VALM o RIENT 5 <br /> W1 OI.twMLLARV3,,C*P Af:3.Bi3 1F340 N.BREIA WAt AtiiE <br /> Generator's Phone: STCx-KTON,c.A STOC'T*3Fi,CA <br /> 6.Transooner 1 Company Name U.S.EPA ID Number <br /> !.h TrM-r POrI dt(t ii Vii JIMA <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> 8.Designated Facility Name and Site Address RKOkWHVV Road Lwwft U.S.EPA ID Number <br /> t3M4tpow :; <'TYatdi <br /> `,rai:2e148.CA 9SM7 <br /> Fa s Phone: <br /> 9.Waste Shipping Name and Description <br /> 10.Containers 11.Tata) 12.Unit <br /> No. Type Quantity WWol. <br /> 1 <br /> c • #ai +t�Jt�S 5!)tt OP Dt. y <br /> w <br /> 2. <br /> 3. <br /> 4. <br /> S <br /> 13.Special Handling 1 <br /> Instructions and Additional information <br /> T' , <br /> fl'-P' +4+} on0*) v01:: <br /> 14.GENERATOR'S/OFFEROR'S CERTIFICATION:I hereby declare that the contents of this consignment are fully and accurately described above by the proper shipping name,and are classified,packaged, <br /> marked and labeled/placarded,and are in all respects In proper condition for transport according to applicable International and national governmental regulations. <br /> Generator'slOfferor's Printed/Typed Name Signature Mordh Day Year <br /> -.115.Inlema}Jonal Shipments <br /> i 1:1 import to U.S. ElExportfrom U.S. Port of emrylexit: <br /> Transporter Sionature for exports only): Date leaving U.S <br /> ( 1¢ 16.Tw.spodmen <br /> er Acknowledgment of Receipt of Materials <br /> 6 2 Transporter 1 Printedliyped Name Signature Month Day Year <br /> IL <br /> z Transporter 2 Printedliyped Name Signature Month Day Year <br /> a � <br /> V.Discrepancy <br /> 17a.Discrepancy Indication Space ❑ ❑Full Re et tim Quantity Type ❑Residue Partial Rejection j <br /> Manlfeet Refererim Number. <br /> r 17b.Alternate Facility(or Generator) U,S.EPA ID Number <br /> v <br /> LL Facility's Phone: <br /> W 17c.Signature of Alternate Facility(or Generator) Month Day Year <br /> a <br /> yz <br /> 4 <br /> _,: Rs <br /> 18.Designated Facility Owner or Operator.Can fication of remipt at materials covered by the manifest except as noted In Item 17a <br /> Printed/Typed Name N Month Day. YeArl, <br /> 169-BLC-0 6 10498(Rev.9/09) TRANSPORTER#1 <br />