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NON-HAZARDOUS t Generale ID Numb2 Page 1 0l 3.Emerge Response Phare 4.Waste Trac u <br /> Ak WASTE MANIFEST N/A ( f (877)258-8285 �MT6350-00? <br /> 5-GPIIf9t�1`I'MI MMUC G ryH19.1 °raY�I it l S address) <br /> 5508 Lonas Dr 1501 N Jack Tone Rd <br /> Knoxville,TN 37909 (885)474-2826 Ripon,CA 95366 <br /> Generator's Phone - <br /> 6 Trans er 1 Cam ny Name U.S EPA ID Number <br /> Pg derE�nVhrimental Services Inc CAR000180737 <br /> 7 Transporter 2 Company Name U.S EPA ID Number <br /> 8.i: iame and Site Address U.S EPA ID Number <br /> 1105-CAIrport Rd <br /> Rio Vhta,CA 94571 (707)3743834 WA <br /> Feclf l's Phone <br /> 9.Waste Shipping Name and Description 10 Con anurs 11.Total 12.Unit <br /> No. Type Duarrtity WINol <br /> X; t Non-Hazardous ftste,Liquid (Tank Rlnsate) 01 TT go G <br /> Z r <br /> 1U 2- <br /> r3. <br /> 4 <br /> 13.Special Handling Instructions and Additional Information n r� <br /> PO 047844 Trude C/_Cy} G <br /> Job#20-16350 <br /> 14,GENERATOR'S/OFFEROR'S CERTIFICATION:I hereby declare that the contents of this consignment are fully and accurst ,,descn the proper shipping name,and are classified,packaged, <br /> markeI and acarded,and are to all respects In proper condition for transport according to appiicaWe international d rnmental regulations. <br /> GeneratoTic <br /> ri' ed/Typed N Signature _ Mgn <br /> r (J <br /> 15.InterMlional Shipme ❑kmpon to U.S ❑Ev.3 from U r Pat of eebyrexa: <br /> Tran ,rler S-.nature Ifor exicrts only) Data le J S <br /> cc 16-Transporter Acknowledgment of Receipt of Materials <br /> LLI <br /> Tr �nrler 1 Prirri`.7rped� ,� i Sgn rdh Day Ypnt– <br /> a _ <br /> En <br /> Transporter 2 Pnnted/Typed Name SignaW Void Day Year <br /> L-J- <br /> 17 Discrepancy <br /> 17a.Discrepancy Indication Space <br /> ❑Quantity El Type ❑Residue ❑Partial Rejection ❑Full Rejection <br /> Mandest Reference Number <br /> r t 7b Alternate Facility(or Generator) U.S EPA ID Number <br /> a <br /> U <br /> ua <br /> Facility's Phone <br /> w %.Signature of Wlemate Facility(or Generator) Month Day <br /> a <br /> Z <br /> cti <br /> C111 <br /> LU l <br /> 18.Designated Facility Owner or Operator Certification of receipt of materials covered by the manifest except as noted in item 17a <br /> PdntedRyped Flame - 1 re _ �r/ --- —-- – h! r h qr���,yr� <br /> _ <br /> ?MA'a0l, 1 /M � — //`/!'s CLQ• r/'�'G.J) <br /> 169 9LC-0 6 11977(Rev.9/09) DESIGNATED FACILITY TO GENERATOR <br />