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t <br /> NONHAZARDOUS 1. Generator 10 umber 2. Page 1 of 3. Emergency Response Phone 4. Waste Tracking Number <br /> WASTE MANIFEST <br /> 5. eneraloes Name nd Mail ng Address p �Gen`erat&s Site Address (if different then mating address) <br /> /V3' :` 511 1�C., - CZ - L ` 0t tv 7 T nl <br /> io TR uI , CA <br /> Gnereee: <br /> 6. Transporter 1 Company Name U.S. EPA ID Number <br /> 7, Transporter 2 Company Name U.S. EPA ID Number <br /> 8. ggsignaled Fac Iry erne and Site Address �� U.S. EPA ID Number y <br /> twt <br /> LL <br /> �50�tiv L'tl LS LIS • (' <br /> r Fadlll 'Aofis UP%j O4 <br /> 9. Waste Shipping Name and Description f0. Cont inam 11. Total 12. Unit <br /> No. Type Quantity WWd. (' <br /> p O <br /> o I <br /> w <br /> Z 2. <br /> 3. <br /> 4. <br /> 13. Special Handling Instructions and Addillonal Information <br /> OSP � W v .,•_ <br /> t <br /> 61t) <br /> 14. GENERATOR'SIOFFEROR'S CERTIFICATION: I hereby declare that the contents of (his consignment are fully and accurately described above by the proper shipping name, and are classified, packaged, <br /> ��. marked and Iabeledrplacarded, and are in all respects In proper condition for transport according to applicable Intern d national governmental regulators. d <br /> GeneraloeslOfferofs Pdnled(Typed Name SI a Month Day Year <br /> 6?*A V <br /> r 15. International Shipments ❑ Import to U.S. ❑ Export from U.S. Pod of entry/a) il: E <br /> Transporter Signature for exports onl : Date leaNn U.S.: <br /> �r ¢ 16. Transporter Admov4edgment of Receipt of Materials <br /> Tmnspoder i ' yped Name St Month I /rYapr <br /> j1q <br /> z Transpo r 2 Prinled/Typed Name Slgn onlh Day Year <br /> 17. Discrepancy <br /> I <br /> fire, Discrepancy Indication Space <br /> i' ❑ Country Type Residue PaNal Rejection ❑ Full Rejection <br /> Manifest Reference Number: <br /> 17b. Alternate Facility (or Generator) U.S. EPA ID Number <br /> U <br /> LL Facility's Phone: <br /> W 17c. Signature of Alternate Facility (or Generator) Month Day Year <br /> ti <br /> _z <br /> 0 <br /> 16. Designated Fecifity Owner or Operator: Cedificalian of re Ipt ofTN ats covered by the manifest except as noted in Item 17a <br /> Pdnledrryped Name Signature onth - a <br /> 169•BLC-0 6 10498 (Rev. 9109) DESIGNATED FACILITY TO GENERATOR <br />