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NON-HAZARDOUS 1.Geperator ID Number 2.Page� �8-�4�-3saa Ir!-1 of 3.Emergency Response Phone 4.Waste r cking Number <br /> WASTE MANIFEST / d 0o ��� ,, - <br /> r---��� " v <br /> 5.G etator's Ne an I' Addre s Generator's Site Address(if different than mailing address <br /> 019 <br /> Generators > L Ls cG) O a j(��r� �1' " r. `-7 <br /> 6.Transporter 1 Company Name U.S.EPA ID Number <br /> Environmental L .Inc. CARO 0 0 2 1 7 5 1 3 <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> B.Designated Facility Name and Site Address U.S.EPA ID Number <br /> F azmt TSDF IFIL. <br /> 180 W.N iXft A%*nw <br /> BboMVk9 rn CA 92316 <br /> Facility's Phone: 909 421-2012 ICAD982444481 <br /> 9,Waste Shipping Name and Description 10.Containers 11.Total 12.Unit <br /> No. Type I Quantity Wt.Nol. <br /> cc <br /> bq go <br /> 1. <br /> z 2. <br /> W <br /> (7 <br /> 3. <br /> 4. <br /> 13.Special Handling In tions and Additional Information <br /> g - �zJ)VAj I X310 IN-1 <br /> N101GDcoZ- <br /> 0 �J <br /> 14.GENERATOR'S/OFFEROR'S CERTIFICATION:I hereby declare that the contents of this consignment are fully and accurately described 01ve 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 gnd national givq mental regulations. <br /> Generator's/Offeror's Printed/Typed Name Signature --�c Month Day Year <br /> 15.International Shipments <br /> F ❑Import to U.S. ❑Export from U.S. Port of entry/exit: <br /> Transporter Signature(for exports only): Date leaving U.S.: <br /> w 16.Transporter Acknowledgment of Receipt of Materials <br /> Transporter 1 Wn7ped N SignaMonth DaYear <br /> i yy 1 <br /> z¢ Transporter Pr drTyped Name Signa, Month Day Year <br /> 17.Discrepancy <br /> 17a.Discrepancy Indication Space ❑Full Re ection <br /> ❑Quantity El Type ❑Residue ❑Partial Rejection j <br /> Manifest Reference Number: <br /> 17b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> J <br /> V <br /> rai Facility's Phone: <br /> LOU 17c.Signature of Alternate Facility(or Generator) Month Day Year <br /> z <br /> z <br /> W <br /> O <br /> 18.Designated Facility Owner or Operator.Certification of mate Is covered by the manifest except as noted in Item 17a <br /> Printecirry Name Signature Month Day Year <br /> I[~ 44 Z_ 1 2.__ <br /> 169-BLC-0 5 11 (Rev.9/09) DESIGNATED FACILITY TO GENERATOR <br />