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. _ INTL GENERATOR 11( NON-HAZARDOUS <br />WASTE MANIFEST <br />1. Generator ID Number <br />CAC 0 0 3 1 4 1 8 5 0 <br />2. Page 1 of <br />1 <br />3. Emergency Response Phone <br />80062491:38 <br />4. Waste Tracking Number <br />NH 1 1- 2 1 - 0 0 4 8 3 <br />5 Generator's Name and Mailing Address Att Mike Dowger Generator's Site Address (if different than mailing address) <br />Ryder •Fransoortation Services Ryder Transportation Seni.ces <br />505 Eagleview Blvd. 20920 S 99 Frontage Road <br />Edon PA 19341 Ripon CA 95368 <br />Generator's Phone: 010 Q889478 I <br />6. Transporter 1 Company Name U.S. EPA ID Number <br />Patriot Environmental Services ICADO 5 3 8 6 6 794 <br />7. Transporter 2 Company Name U.S. EPA ID Number <br />8. Designated Facility Name and Site Address U.S. EPA ID Number <br />Kirby Canyon Recycling and Disposal <br />910 COYOTE CREEK GOLF DR <br />Morgan Hill CA 95037 <br />Facility's Phone: 411R 7 7 P ?MR C-:Ar CiR 7 :), '') 10d 1 <br />10. Containers It. Total 12. Unit <br />9. Waste Shipping Name and Description No. Type Quantity WI Not <br />Non Hazardous Waste, Solid (Soil Contaminat.ed mil Diesel) <br />0 0 1 CM 00015 I <br /> <br /> <br /> <br />Special Handling Instructions and Additional Information <br />Joi.D# 11-2 1..— 0 0 482 t j 0 --L) 4.96,-t„ <br />Profile 651048CA <br />Bin* <br />I <br />GENERATOR'S/OFFEROR'S CERTIFICATION: I hereby declare that the contents oft is consignmen1 we . an .accuraie y descr '• d ibove.ygetipirWVarottifrig. name, and are' ila;sgial, .0%ckaged, <br />marked and labeled/placarded, and are in all respects in pro condition for transport according to applicable interrrptional and national governmental regulations, <br />Generators/Offerors PrintedfT d Nime 77 <br />I/ ((. .3----i_ 1---3YiY• - <br />Signature Month Day Year <br />(11/` `------- - I Oil i , <br />Interne ional Shipments Li from U.S. POrt o /exit: Import U.S. <br />Transporter Signature (for exports only):Dale leaving U.S.: TRANSPORTER Transporter Acknowledgment of Receipt of Materials <br />Transporter 1 Printed/Typed Name Signature Month Day Year <br />1 1 <br />Transporter 2 Printed d Name Signature I Month Day Year <br />1 .-•--1 ' <br />r._-___,,/'' 10111 S 141 ......- DESIGNATED FACILITY -311.- Discrepanc i <br />Discrepancy Indication Space <br />Quantity Type Residue Partial Rejection Full Rejection <br />Manifest Reference Number: <br />Alternate Facility (or Generator) U.S. EPA ID Number <br />Facility's Phone: <br />Signature of Alternate Facility (or Generator) Month Day Year <br />18 Designated Facility Owner or Oper : Certification of receipt of materials covered by the manifest except as noted in Item 17 <br />Printed/Typed Name '\ Signature onth 13 <br />tut, <br />DESIGNATED FACILITY TO GENERATOR 169-BLC-0 5 11977 (Rev. 9/09)