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NON-HAZARDOUS 1.Generator ID N <br /> umber 2.Page 1 of 3.Emergency Response Phone �t 4.Waste Tracking Number <br /> WASTE MANIFEST e 1L 1Awtj 1 XIIb33 �QO <br /> 5.Genera to s Nary�an�1 aili dd ess m Generator's Site Address(if cliff�[eni than mailing addre ) <br /> IA�fWI faut�C M�1' Rm 1/�(1tWl �AGh+L �yll�oA <br /> ry oo 00w lag �o,p ►0 30 c- P ed <br /> Generoal- 'it 625 � I fr&AcAi C,irn > CA 012a31 <br /> 6.Transporter 1 Company Name U.S.EPA ID Number <br /> -h-i d-} CAD O U b -W <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> 8.Design ed Faci�yy Name and Site Address �( U.S.EPA ID Number <br /> yJaST_- Lc tcn fo"s ' X 0 Gvo ih 1 J <br /> 367-5 FbVr" k;1K La>� <br /> Fa�, tR nA G k`1, CA IN SgS <br /> 9.Waste Shipping Name and Description <br /> 10.Containers 11.Total 12.Unit <br /> No. Type Quantity WtNol. <br /> o ' Navi, Wa�,O wA3lv� Sot; <br /> 0 <br /> W 0,{5-t CM 4'. 0MO <br /> z 2. <br /> w <br /> c� <br /> 3. <br /> 13. Special Handling Instructions and Additional Into atio <br /> Oil I TIM <br /> ))�onr�rnAE�lT <br /> �� .21V33 <br /> 14.GENERATOR'SIOFFEROR'S CERTIFICATION:I hereby declare that the contents of this consignment are fully and accurately described above by the proper shipping name,and are classified,packaged, <br /> marked and Iabeledlplacarded,and are in all respects in proper condition for transport according to applicable international and national governmental regulations. <br /> Generator's/Offeror's Prinled Typed Name Signature Month Day Year <br /> 1 1 1Q 3 <br /> 19 <br /> 15.Ince ahonal Shipments ❑Import to U <br /> z po ❑Export from U.S. entry/exit: <br /> Transporter Signature(for exports only): Date lea <br /> w 16.Transporter Acknowledgment of Receipt of Materials <br /> Transporter 1 P Typed Name Sign je � Month Da Year <br /> CAL <br /> a ype <br /> Transporter 2 Pn fedi d Name Sign re loonth D y Year <br /> H <br /> 17.Discrepancy <br /> 17a Discrepancy Indication Space <br /> ❑Quantity ❑Type El Residue ❑Partial Rejection El Full Rejection <br /> Manifest Reference Number: <br /> 17b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> _D <br /> U <br /> a <br /> LL Facili 's Phone: <br /> w 17c.Signature of Alternate Facility(or Generator) Month Day Year <br /> H <br /> a <br /> z <br /> c7 <br /> w <br /> w <br /> 0 <br /> 18 Designated Facility Owner or Operator:Certification of receipt of materials covered by the manifest except as noted in Item 17a <br /> Printed Typed Name Signature <br /> DESIGNATED FACILITY TO GENE OR <br />