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ti <br /> NON-HAZARDOUS 1.Generator ID Number , 2.Page 1 of 3.Emergency Response Phone 4.Waste Tracking Number i <br /> WASTE MANIFEST NOTREIQURt�P f4J73J2596 <br /> 5.Generator's Naampge and Mailing Add'reasss p Generator's Site Address(it different than ma!PE g address) <br /> ON�US <br /> Ono �990� Rebus .�. 7'71010 �CA 8=7 <br /> Generators Phone: #` <br /> 6.Transporter 1 Company Name <br /> U.S,EPA ID Number` <br /> �• <br /> 7.Transporter 2 Company Name 5U.S. <br /> U :EPA iD limber <br /> B.Des;gaare Fa'iit�Name an Site ress x. U.S.:EPA ID Number. <br /> £y Ram Refs" I <br /> Facili 's Phone: ,.CA MW - <br /> 9.Waste Shipping Name and Description ~,Y <br /> io.Conlainers 11,Total 12.Unit <br /> No. ' Type, Odantity W1.1Vol' <br /> 1. <br /> W , <br /> 4. <br /> ^6v ) <br /> 11 Special Handling Instruc1or5s and Additional Inivnnativn <br /> am applinlWhot& 24 how a+rimrgimmy nam( )4244KMP~ 421,2107702 <br /> �1d11f � � <br /> r_ ?i pfuw I X2-60 CW 21160 <br /> 14.GENERATOR`SJOFFEROR'S GER nFIOATIGu:F Ferebj deware that the aanta*of this cvnsgrrnml are tulfe ani accumial¢,de=criited abcrogby ft proper ftfing name,u5d are classified,packaged, <br /> MOW and iabsledrylncardexl,and are in all respects b propercurrJiliX for ifarr pico-accvjN Fa applkatle iilemapal and nadmal grnemfnerral regulg'gns-' <br /> Gvnem*Ir'S'glrerolSPiiiledlTypeJRant SVgrtaGlre E,' Wrxh Day Year <br /> Ala ENC b"f �S K p 1 )[ <br /> r t S.kriemai Diet SNpTa5t5 ) <br /> o ' Pur;alenhyr�cl: <br /> ❑kn rt m U.B. ❑ERpeTE from U.. <br /> Trans r1erS'nature tW ex ortscn Date'icavli U.&= <br /> 16.Transporter Acknowledgment of Reoeipi of Matcrials r <br /> Transporter 1 P medlTyped Name Signature // Maw Day•.. Year <br /> z Transporter 2 Pdntecffyped Name Signature> Month Day Year <br /> 17.Discrepancy <br /> 17a,Discrepancy indication Space ❑ e <br /> quantity Typ �` Ll Residue El Partial Resection 0 Futl•Rejection <br /> Manifest Reiererice Number. <br /> 17b.Altemate Fadli y(br Generator) U.S.EPA ID Number <br /> Facility's Phone: - <br /> © iia.Signature aFAll9rnate Faolity ior Generator) fknlh Day -.. Year <br /> z <br /> 1$,D nib n3tvd Fxfi�,q mar ar;gpsraMr:CtalilitaGO1 of rico pf o!matenais;co+ered by.t�r marifesf sxcEpt as Ivied 0IWm 17ar <br /> Prinledrryped Name - Signature M ShDay <br /> " - - I ., - s �Yes <br /> --�----�'""'"__---�--- <br /> TRANSPORTER#3 <br /> 169-BLC-O 5 11977(Rev.9109) >+ <br /> I <br />