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<br />NON•likZARDOUs
<br />WASTE MANIFEST
<br />1. *eget ID Ntinthor
<br />Ma*, 4.
<br />2. Page 1 of
<br />1
<br />3, Emergency Response Phono
<br />877-256,826S.
<br />4, %Vimlp TraakIng Number
<br />22a60294004 • Generator's Narneeclkinlln , .•
<br />- 7 Wit* le
<br />5tOtiftirCA:95206.- '.
<br />Generator's Phone: 7o4.94447009"
<br />,
<br />GoneratoriSite Address Ili different llion tallreiglickfrifis)
<br />' Nifidim
<br />Transporter 1 Company Name US, EPA ID Number
<br />- , POrlidtr.:ErriktginelelSeilikAP, I CA,IR0100.1,80 737 Transporter 2 Company Name U.S. EPA 10 Number
<br />/acilittt
<br />Designated
<br />
<br />Faddy Name and Site Address U.S. EPA ID
<br />Pl'
<br />flint .4".,•• ;••• : ., - 707 . . .
<br />Number
<br />4- Waste ShippIng Name and Dascrimion 10. Conlarnera 11. Total 12 OA
<br />No. Type Quantity WiiVel.
<br />-,!24
<br />cc I ta •
<br />L,Non-Hezzedous Waste SdicttHydrocarbari
<br />lc, : - - -..,t l';',43.. ''' ,..- :•tit t,,,;
<br />.1.'"
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<br />i:-
<br />ii ...
<br />11;q4,01 4%
<br />17 :-4L
<br />- 1. w j: n - .o ,
<br />ra•
<br />13. Special Handing Inatnicfmica,godAdddien
<br />.26O9
<br />' 1 01000/1k0440-L..
<br />', 7,
<br />InfamiatIon
<br />'
<br />14,, 4ENEBATOR'S/OFFEROR'S CERTIFICATiON; I hereby declare thai.tha contents Girls consignment an Mly and *oral* desetted above by the proper ih(pping name, and we classified, packaged, -
<br />'? (lW1**Iabtf.e4034alFled, and are taal I'Mects 16 fIloPer Ccoticill for tian8Port sccorcPglo-BPPr!:c(INP Inta0a*al and:nationaigoyerrutiontelregUlations.
<br />GeOfator'apfleror'aPrintecliTyped Name , . Senator ,
<br />& ..ff-.'—'----
<br />Mtx.a.1 t?.Y Ygar
<br />'civ. isty 6 e. k4 0
<br />
<br />&I.5 ZEt-CAL. ZO (503,C-P4,1S I. I -.1. 1,1q I 2,-Ci
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<br />t ••••,.,
<br />ilnititiarldiOrOfiliit§ ri 1...._, irnportv U.S, E,vor1lrom u,s. Part oiert(rytex(t
<br />TranspedaSionaNre„(lor worts tty, Date.leavirtopS.: . , TRANtOORTER' 1k yiiii r . \i*.iiii001 R0001.0.:.440001s .
<br />Tt.......*(101,•r-PdnWY.004 .1 14;00: Month Day Year ..0.7:::....: . ....- • .
<br />I .-7 l'iq I it
<br />Trah,sper(ilaZ Printi,fda&I kne. *WO' . Mandl: . " Day Year
<br />I DESIGNATEDTACILITY 17..Dykeparyty
<br />11.8.-O0briOnty InOcation Space Quantity U Type
<br />Manliest
<br />111
<br />,.
<br />Residue 0 Pattie! Rejection Drill! Reflex
<br />Reference Number:
<br />17b, Alternate Feeilly (or Generator) U.S. EPA 10 Nattier
<br />*PO POrsn:
<br />711e:anaftlie efAllemete Facsify (or Gerieralor) MOtritl . Day Yaln•
<br />---'
<br />d • ...
<br />4 , • .
<br />18. Designated Facility Owner or Operator. Codification or receipt oforiels cove day the manifest except as noted In Item 17‘
<br />Printed/Typed Nome Signoltiro m n
<br />I
<br />169,BLC-0 6 10498 :(Fiev,-9/09)
<br />
<br />1\1 DESIGN ATOD FACILITY TO GE hERATOR
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