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0-/j <br /> NON•HA7ARDOUS 1-Generator ID Number 2,Page 1 of 3-Emergency Response Phone 4.Waste Tracking Number <br /> WASTE MANIFEST NOT REQUIRED 1 88154=41M 4OD40-48-W7 <br /> 5.Generator's Name and Mailing Address Generators Site Address(if different than mailing address) <br /> 7-ElrM 7-Wiwn SbfY No. <br /> P.O.On 711,Doin TX 75221 4627 Drs Vlnd Dr.,3fddl bn,CA 9=7 <br /> Generators Phone: PM <br /> 6.Transpode Nam U.S.EPA Ifl Number <br /> f fJ <br /> NOT REQUIRED <br /> 7.Transporter 2 C mpa Name U,S.EPA ID Number <br /> B.Designated Facility Name and Site Address U.S.EPA ID Number <br /> Waft CorwoKOn-PolttelHft Lance <br /> 3675 Pb>:iro Hff LW*,Ste.CA 94686 NOT REQUIRED <br /> Fadlit''s Phone: <br /> 949' 1 <br /> 9.Waste Shipping Name and Description 10.Containers 11.Total 12.Unit <br /> No. Type Ouantity Wt vol. <br /> 1. <br /> tr <br /> a Non Hawdow YIIbM,SM{ScO Bal DT 14 Y <br /> w <br /> LU <br /> 3. <br /> 4- <br /> 13.Special Handling In4lrudions and Additional Information <br /> SO.'99-10D% MOM N0: PMF MIM <br /> Dom:O-I% <br /> Wim swop ftb WE when hmrvgft or to reqtimd by the TSDF Prod No:40Gl6I1 <br /> 14.GENERATOR'S10FPEROR'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 labeledlplacarded,and are in all respects in proper condition for transport according to applicable international and national govemmental regulations- <br /> Generator A + 411 WNW>dfC �����+`�f��� Mgfrth D y Year <br /> 15.Intemational Shipmerits lea <br /> l <br /> ti Import to U.S- Export from U.S. Pon of entryleAt: <br /> Transporter Si nature for exports only): Date leaving U.S.: <br /> cc 16.Transporter Acknowledgment of Receipt of Materials <br /> w <br /> � Transports n N I� Signature1�4� <br /> �r� Day Year <br /> o <br /> a <br /> fA <br /> E Transporter Printed/Typed Name Slgnature Month ay YW <br /> x <br /> 17.Discrepancy <br /> 17a.Discrepancy Indication space ty Type ❑Residue j ❑Full Rejection <br /> ❑quanti ❑T ❑Penial Re action <br /> Manifest Relerenoe Number- <br /> 17b-Alternate Facility(or Generator) U.S.EPA ID Number <br /> U <br /> Facility's Phone: <br /> 17c.Signature of Altemate Facility(or Generator) Month Day Year <br /> a <br /> x <br /> c� <br /> m <br /> w <br /> 0 <br /> 18,Designated Facility Owner or Operator:Certification of receipt of mater red by the manifest except as noted in Item 17a <br /> Pnntedr-yped Name _ Signaturen 47ay0,Ax-- P�? , Yea <br /> 169-BLC-0 5 11977(Rev.9109) DESIGNATED FACILITY TO GENERATOR <br />