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rnlIlMNIMIMIMIEPSMWTQEWMaVZAWKW2-frarAaaVtt,:- k70.34/WWW„ GENERATOR NON-HAZARDOUS <br />WASTE MANIFEST <br />1. Generator ID Number <br />Not Req u ired <br />2. Page 1 of <br />I <br />3. Emergency Response Phone <br />*388-423-EXIW <br />4. Waste Tracking Number <br />1 2 2 0 2 1 4 0 2 8 <br />,-..1 <br />Generator's Name and Mailing Address Alt Eft,k va Generators Site Address (if different than mailing address) <br />Bonnie Plants <br />27.5 East WW1 Rood <br />Olden CA 96238 <br />Generator's Phone: 209 aa7-73C0 <br />Transporter 1 Company Name U.S. EPA ID Number <br />Paverinan Integrated Services. IRC. !CA00014338 <br />Transporter 2 Company Name U.S. EPA ID Number <br />I <br />Designated Facility Name and Site Address <br />re RI Hiiic.i Lukcilitl <br />31375 POUero NIK Lane <br />Sttivan CA 945a5 <br />Facili is Phone: 707 432-4627 <br />U.S. EPA ID Number <br />Not Reguired <br />. <br />, <br />Waste Shipping Name and Description <br />Containers Total Unit ' <br />No. Type Quantity Wt./Vol. <br />l'ion-Hazardous iithsta Solid (Seil) <br />DM SCO - <br />, <br />Special Handling Instructions and Additional Information <br />Wear proper PPE while handling. Weights or volume.-3 are appoximate. <br />AIS job#91006 -015 -18 / Profile: P.FIT,w -21 -1079 <br />1)(51.5. <br />14, GENERATOR'S/OFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully a d ac Jrately described air <br />marked and labeled/placarded, and are in all respects in proper condition for transport according to applicable inte all 41 and national goy <br />a by the proper shipping name, and are classified, packaged, <br />mental regulations. <br />Generators/Offerors Printed/Typed Name <br />AS On Behalf a GenereSof .114ou-gniteiting <br />Signature A <br />1 Alli APPA\, <br />Ih. 2Dayi Year <br />,. TRANSPORTER lan .-...m...-- 15. International Shipments Import to U.S. Export from U.S Port of entry/exit: ' <br />Transporter Signature (for exports only): Date leaving U.S.: <br />16 Transporter Acknowledgment of Receipt of Materials <br />Transporter 1 Printed/Typed Name <br />/4 <br />Signature . Anth Day Year <br /> ' 11--MiE 2'. i <br />ir <br />I '4'4 Id <br />Transporter 2 Printed/Typed Name Signature Month Day Year <br />I I -.4E-- DESIGNATED FACILITY -11.- 17. Discrepancy <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 />17e. Signature of Alternate Facility (or Generator) Month Day Year <br />II <br />e <br /># <br />A <br />At <br />18. Designated Facility Owner or Operator: ertification re ipf of materials covered by the manifest except as noted in Item 7a <br />Printed/Typed Name Signature <br />liE3r1 f/fai <br />169-BLC-0 5 11977 (Rev. 9/09) <br /> DESIGNATED FACILITY 0 r- ei-Vc;