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NON-HAZARDOUS 1.Generator ID Number 2.Page 1 of 3.Emergency Response Phone 4.Waste Tracking Number <br /> WASTE MANIFESTfq t boa -bZ-I -`1l3 b 02-1-11010"U <br /> JQ <br /> 5.Generator's Name Mail'u�ggdr�rQGs Generator's Site Address(if different than mailing address) <br /> lO0 �oq�J JJ <br /> ty co ;L lets 5k�e.�.S��° 1Z3o ►oat3 Qml'C Qa►• ��,5.231 ) <br /> o rha l'>e►, big 1 °I Arun cJ� P i <br /> Generator's Phone: <br /> 6.Transporter 1 Company Name U.S.EPA ID Number <br /> P,m V of '2A% yno m<m6A Swami c�8 C,�r v aS3 8 b b-4-9 L4 , <br /> 7.Transport'er 2 Company Name U.S.EPA ID Number <br /> .``V <br /> 8.Designated F cility Name c�a d ." U.S.EPA ID Number <br /> Cho otna <br /> �eacN,, CA 9n►3 CSf�I $��'- b�' 1_ CAO 0;t?Ila Q0 19 <br /> Facilit's _ <br /> 10.Containers 11.Total 12.Unit <br /> 9.Waste Shipping Name and Description <br /> 11 No. Type QuantityWtNol. <br /> 1. A r� flat A� WEAK. J���C� a <br /> ccIV ' <br /> a C AVA%,4r- dlx.W S C-1,,V I N� F b <br /> � 2. <br /> 3. <br /> a' <br /> 4. <br /> 13,Special Handling Instructions and Addilio I Irjf crit eAk- <br /> 4' 11-11'0031-a- J <br /> 1 ?3 <br /> 14.GENERATOR'S/OFFEROR'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 labetedlptacarded,and are In all respects In proper condition for transport according to applicable International and national governmental regulations. <br /> Gene'ator slOHeror s Printed/TNam e� �G Ylt7JiN'^( O Signa Month Day Year <br /> 1i�1 55TTCC Z ►Z 7-0 <br /> , <br /> 15.Inte nett onal Shipments Q Export from U.S. ort of entrylexit: i <br /> ❑Import to U.S. xP <br /> Trans er Si azure for exports only): <br /> Date leaving U.S.: 't <br /> cc w 16.Transporter Acknowledgment of Receipt of Materials ' <br /> Yr, <br /> Transporter 1 Printed/Typed Name Signature Month Day Year <br /> o i <br /> zSiDoth Day ear r *j <br /> 4 Tr rt Print d am - <br /> 17.Discrepancy <br /> 17a.Discrepancy Indication Space El Quantity Type Residue <br /> ❑Partial Rejection ❑Full Rejection <br /> Y y <br /> Manifest Reference Number: n l <br /> 17b.Akemate Facility(or Generator) U.S.EPA ID Number btu <br /> ua Facility's Phone: <br /> F17c.Signature of Alternate Facility(or Generator) Month Day Year i", <br /> i <br /> W <br /> W <br /> 18.Designat d F ilily weer ar Operator:Certificat of ipt of materials covered by the manifest except as noted in Item 17a <br /> Signature Month Da a <br /> Prints <br /> tllfd/Ty ed Nae ` I n� R �J�+ , <br /> 169-13LC-0 6 1048(Rev.9109) DESIGNATED FACILITY TO GENERATOR <br />