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1,2104!2009 11:24 12093341373 FLAGCITY CHEVRON PAGE 03!04 <br /> , R1 <br /> Please print or t e.(Form dealgned for use on ellto 12•pitoh)typewriter,) <br /> NON-HAZAR60tis 1,&.nerntor ID Rtmher 7.Pogo 1 of 3.Emomminy Resporiw Phona h w rta Racking Numuor <br /> WASTE MAMFEST i;ALI:N.;ifr3r11AOr4 I 1 41(?f}. atE;t••i'a9� 10,,? 414 <br /> S.Ganerstor'3 Name and Melling Arklress Ganer"gi,Site Address(7 nlffamnt then melting addreaa) <br /> FLA(;A(;Ct TY C+k-VF't*4 <br /> 647'1 CANTr94..*I z <br /> f,E:'k GA W1,12 <br /> Gonerstoro Phone:3(.14101-819) U.S.EPA lD Nlllnher <br /> 6.Tranmpolter 1 Compeny Ntlms C.,A1:.4{,?f,I AOA149 <br /> j#h)4'14A A4aDS,,R,;14.tkIX MSI,WK. <br /> U.S.FPA ID Number <br /> 7.Transporter 2 Compary Name <br /> 3,DaNgnnlctl I'aolllty Namo and SiteAddrM3 I.I.S.EPA ID Numftnr <br /> rrE.Pt+}^k'�Aa�+fiti;.4atw+ 4�f£,�.J"y�'+,4..3.tr s: 4�H(.1ti+?4?Jt tf3,� <br /> 41 ► ��ti 4 4t 4 4 4?f,:VK RLY <br /> i�.d tr,;:6ff'►�;~ 4F # "nrt� (:,,n 9614 <br /> reclllt rs Phone: <br /> An Db,U.S,DOT DaRaiprion(including Proper Shipp M Namc,NO Wml Class.Ip Nut�ltx, 111,Cnnlaintlrs 11.Tow 12,unit <br /> KM nnn PixiiIng Group(Ir any)) No. Ty:no ')uanthy WtJWI, <br /> el,�t,►;. y , kal�1 i 4z <br /> 1. f<N, y'it;N .1: a tft.Ata. �ilial.; S i <br /> o : e;kl.\.I►Y T44�tt3�: <br /> w <br /> z <br /> u.r <br /> 0 <br /> IT <br /> � I <br /> I <br /> r. <br /> 13.Special I�agrl�p9 shucttona and AdctUlarkvl I„rnrmokon <br /> t <br /> I <br /> 14, CSNERATOR'S CERTIFICATION: I codify Jho Inilpflais descnbcd lhnve on UlIn mFlltlfeat am not,^uhlert to federal rnquin inns for reportinn pl»per dlapoaai of Hozarilir.Waste. <br /> Gnrerator',�Offome,i PrintedlTyped Namc Signaaue Month Day Yner <br /> t <br /> -A 15.ntamoUnnal Shipments r ❑Export Irom ll�, Pnrt ofA LI entry axN: ..____..._ ._ •_ <br /> F r-I Impartto LI.S. <br /> z 'Transporter signrttura(far exports only); Data leaving U.S. <br /> A: 16.Tr msportet AdmoNladgmant of Receipt of M^�ltodnla <br /> Transponnr I Prin frypod Nimno jy Sipneturo f ' Month Day Year. <br /> Tnnnr oN&2 Printedfrypprf Name Slgnnlum Month Day Yr�+r <br /> r <br /> 17.Dk crepantN �-•^^� <br /> 17o,DI!,mloancy Indication Space 0quantity ❑Typo ❑R.n.,W111e LJ Partial Rolaotion ❑FIIII R5091rxt <br /> P.anifcsf i�rteranca NuhbCr: <br /> 17h,Altcnntn facility(or Genormor) U.S.EPA ID Norther <br /> U <br /> < Fs0ty'.n Phare: _ Manih Day Year <br /> a 17c,Stgnahtre of Aliprnnte Facility(or Gonnrainr) <br /> L- <br /> Q — <br /> ca <br /> v3 <br /> Lu <br /> 18.D9slgn rtad Fn Oiwnr nr Ornratat Cardllcatktn of recoil of materials r avrred by the Inn meat except as ranted in 11em 17e <br /> Month DaY J <br /> Prinledrryped YaRNa Signature <br /> I <br /> frNH4U1•C•G11 <br />