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0 <br />CC <br />0 <br />NON-HAZARDOUS WASTE MANIFEST <br />Please print or type (Form designed for use on elite (12 pitch) typewriter) <br />PIVINI—MALAHLJOUb <br />WASTE MANIFEST <br />1. Generator's US EPA ID No Manifest <br />Document lin ? Pa;)e I <br />III 3. Generator's Name and Malang Address <br />iV 6 kaki-. i'iri' idli WAS U.ii.,,; <br />1,.'.;:lr4, !ThRNER RD <br />III CA <br />4 Generator's Phone ( ...,',.',:-7' 333-56.1.1 <br />it 5 Transporter 1 Company Name 6. US EPA ID Number A Slate Transporters ID <br />'PAENTAL it Transporter 1 Phone <br />7 Transporter 2 Company Name 5. US EPA ID Number State Transporters ID <br />IIII I Transporter 2 Phone <br />9. Designated Facility Name and Site Address to. US EPA ID Number <br />III <br />Stale Facrlity's ID <br />05776 I CAL00007088"/ <br />F Facility's Phone <br />ail II. WASTE DESCSIPTION <br />No. <br />12 Containers <br />Type <br />13. <br />Total <br />Quantity <br />14. <br />Unit <br />WI/Vol <br />a iZO H ARDOUS WASTE LIQUID0M Asi-e" <br />1 2-1/4—k <br />4 <br />1 <br />III G. Additional Descnplrons for Materials Listed Above <br />41 <br />III <br />H Handling Codes for Wastes Listed Above <br />Special Handling Instructions and Additional Information <br />C,014 i ik, i C, a ii:1-4 i f0. ,(2. i -460- 4/4 .1.i3OMOP lrEtNiNa4 Gif-j ' .-i-; t,<,4,- , ,- 4,0 .. i ii iSt 4 .illi3 <br />04.5 ' APPROPRIAFE PFRSONAt PROTE:('TIVF FOIJIMUN I <br />113 E '11.' <br />ifiMairifirMSIMairMilirilrariMErirMaral <br />GENERATOR'S CERTIFICATION: I hereby certify that the contents of this shipment are fully and accurately deathbed and are In all respects <br />in proper condition for transport. The materials described on this manifest are not subject to federal and state hazardous waste regulations <br />Ilk I Date <br />Printed/Typed Name Signature Month Day Year <br />I I <br />T 17 Transporter 1 AcknorMedgennent of Receipt of Materials <br />R Date <br />A PrIntecVTyped Name <br />N <br />S <br />Signature month Day Year <br />I I P 0 18. Transporter 2 Acknowledgement oh Receipt of Materials Date R T Pt intedfrypod Name <br />E <br />R <br />Signature Month Day Year <br />I I 19. Discrepancy Indication Space <br />F <br />A <br />C <br />I 20 Facility Owner or Operator Certilrcatron of receipt of the waste materials covered by hits manliest except as noted on item 19 <br />L <br />a 1 Date <br />T PrrnieWTyped Name <br />Y <br />Signature Month Day Year <br />[ 1 . _