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NON-HAZARDOUS 1.Generator ID Number 2.Page I of 3.Emergency Response Phone 4.Waste Tracking Number <br /> WASTE MANIFEST A 1 g$8 <br /> 5.Gen rators Name aN' Addre G nerator's Site Address(if di rent t n mail' ddress) <br /> �llA1. 4ca%A �lraacl �,^w�'°✓Imwt�� f . �4c��c �-ci�lroad <br /> r4100 clu1�5 Sivtai' - 54y 11730 1 QQ0 E. J&V toad <br /> Generators hone`tr `6 9 1 SVo--t-TI �ervidh CA nV <br /> G9 ct5231 <br /> 6.Transporter 1 Company Name U.S.EPA ID Number <br /> �a ofi eV%"\-o✓Im Az,.1 Vic. CAn0S3 <br /> 7.Transporter 2 Company Name U.S.EPA 10 Number <br /> 8.Desig�Q Facility Namnlfga Address U.S.EPA ID Number <br /> 36 5- <br /> 1PQH 1 S Q 1�11gs Lw►e.. <br /> Facili 's Phor e(S�r C CA 145 �Q} y 3,�'�l a <br /> 10.Containers 11.Total 12.Unit <br /> 9.Waste Shipping Name and Description No. Type Quantity WtNol. <br /> Ix IVOA- kZAV-16 5 wok <br /> 4Z S <br /> W <br /> Z 2. <br /> W <br /> 3. <br /> 4. <br /> 13.Special Handling Instructions and Additional Information <br /> vy-*:: 2251e <br /> -19 -1 d2S <br /> 3 41- kq-0033? <br /> 14.GENERATOR'SIOFFEROR'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 inte 8onal and national govemmental regulations. <br /> Generators/OHeror's Printed/Typed y�me 1`�� Signature Month Day Year <br /> iii!J UI 1 (fox-�� 17-1 '0 19 <br /> 15.I t alional Shipments ❑Import to U.S. El ry <br /> Export from U.S. rt of ent !exit: <br /> Transporter Signature for exports only): Date leaving U.S: <br /> w 16.Transporter Acknowledgment of Receipt of Materials <br /> Trio iter 1 Print ped N e Signature Month Day Year <br /> a <br /> -� I al 4= I/ <br /> aTransporter 2 Printed?yped Name 5 nature Month Day Year <br /> t— <br /> cc <br /> 17.Discrepancy <br /> 17a.Discrepancy Indication Space ❑Quantity ❑Type ❑Residue j ❑Full Re <br /> ❑Partial Rejection lection <br /> Manifest Reference Number: <br /> r 17b.Altemate Facility(or Generator) U.S.EPA ID Number <br /> J <br /> V <br /> Facility's Phone: <br /> w 17c.Signature of Alternate Facility(or Generator) Month Day Year <br /> Q <br /> Z <br /> WW <br /> D <br /> 18.Designated Facility Owner or Operator.Certification of receipt of aterials cov d by the manifest except as noted in IlemV 7a <br /> Len en r—s— <br /> Printed/Typed Name Signaturet D <br /> \,R� I <br /> 169-BLC-0 6 10498(Rev.9/09) DESIGNATED FACILITY O GE ERA O <br />