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NON-HAZARDOUS
<br />WASTE MANIFEST
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<br />4. ViKeIgalitigg NumIlr, .
<br />5. Genemlor'sjpriLt kortf.latting &dress .,, , . Generator's Sito Address Of different than mang address) k...1251f 441 At-vs:Wt.:it .. firtfr.f.4.4 .,-', oteitaasAt ry,,,,k.,)
<br />745 WMdki_tl11/44.1.. ';11.
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<br />Generator's Phone: '," 141.F,5 73.'10 ,
<br />0. Transporter 1 Cs/filmy Name ., U.S. EPA ID Number rrI144g(I' ZIMIXI.ZRV:140/ 't.,!`,f sle :,.:1 1 f.AR 410(11 fl.ti ' .? .1
<br />7. Transporter 2 Company Namo U.S. EPA ID Ntinber
<br />Facitilys
<br />0. Designatelfealy..Nemo and Silo Address U.S. EPA ID Number l'iV4.M.f. WA-.
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<br />IVO Ats, CA. t4iii
<br />Phone:
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<br />9. Waste Shipping Name and Description 10. Containers 1 t. Total 12. Unil 43.
<br />' ' I" `-ii-t(, 1.-1,ke.r•-44-4,,,x1 .4) , vise... No. Type Quantity WUYol. ,A,VAMSihinkttriatti— WadgraZgikakiWNR I ...If i
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<br />11.0
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<br />Speetaftitiv ins,ruclonsend Additional InforMayon
<br />3/474:41 .sretitio
<br />f 44 Z.W(k410)
<br />GENERATOR'S/OFFERORI CERTIFICATION: thereby declare that the cements of this consignment are fully and accurately described above by the proper shipping name. and ere classified, pacloged,
<br />marked and labeled/placarded, and are in all respects in proper condition for transport according to applicable intemationalind national governmental regulations.
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<br />Generator's/Olferor's Printed/Typed Name Signature „dly ... - ...... ...,
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<br />i ..- tr 7 I , ' ., i i , • 1 ..., t .,., ., f .,,., ' C. 0--.1 .15:/r....-.'.', . . ..... .
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<br />Day Year
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<br /> International Shipments Import to U.S. Ei Export from U.S. Port of why/exit. ki) -4 Transporter Signature (for exports only): Data leaving U.S.: • T1:1:1'7WSPORTER Transporter AtkiWedgment of Receipt of Materials fil ,‘.. ?.
<br />Transporter 1 Printed/Typed Nemo Signature Mopth, Day . Year
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<br />Transporter 2 Printed:Typed Name Signature Month Day Year
<br />Discrepancy
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<br />17a. Discrepancy Indication Space El Quantify El 0 Residue El Partial Rejection El Full Rejection
<br />Mandost Reference Number:
<br />c., tO
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<br />fib. Alternate Fealty (or Generator) U.S. EPA ID Number
<br />Facility's Phone: :.•
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<br />17c. Signature of Alternate Facility (or Generator) Month Day Year
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<br />Designated Facility Owner or Operatbr. Certification of receipt of materials covered by the manilest except as noted In Item 17a
<br />F.11 .... Printed/Typed Name Signature Month Day Year
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<br />169.8LC-0 6 10498 (Rev. 9/09) TRANSPORTER #1
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