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169-BLC-0 6 10498 (Rev. 8106) COPY <br />NON -HAZARDOUS <br />1. Generator ID Number <br />2. Page 1 of <br />13. Emergency Response Phone <br />4. Waste Tracking Number <br />- <br />WASTMNIFEST <br />"- in C 9 8 2 � ;1S m � <br />168--4778 <br />B" <br />5. Generator's Name and Mailing Address Generators Site Address (if different than mailing address) <br />a <br />2f.`2_ E A5T 16-rr, 5 T Ft—PEt <br />���� CA <br />RIPON �� <br />21:9 529 ink f <br />Generators Phone: <br />6. Transporter 1 Company Name U.S. EPA ID Number <br />t—d'J i�'a`ti'54T',L neL{:'�wG�. 5E',,;Z I�5, wi�c". t : C !'Cs. P, GO 0 -1:8 8.2 Q.1 <br />:r <br />7. Transporter 2 Company Name U.S. EPA ID Number <br />8. Desig/ntated Facility Name and Site Address U.S. EPA ID Number <br />"URS E 1 STREET <br />L05 ALTS = i Edi CA go, <br />_ <br />!" � tem y, " 0 0 1 r C C. '' 1 <br />Facility's Phone: <br />9. Waste Shipping Name and Description <br />10. Containers <br />'11. Total <br />12. Unit <br />No. <br />Type <br />Quantity <br />Wt.Nol. <br />; 4 <br />1. i:C z r i+al�' ?TEE3 ((`,�C1Ff� 443: 4 F+,TClszsja*' <br />cc <br />O <br />M. <br />ccW <br />a Z <br />W <br />' ; <br />2 <br />3. <br />Y <br />4. <br />4 <br />13. Special Handling Instructions and Additional Information <br />gel) LrF, • DRJM: J,-' VIL FiLTE $ { 7t � 5. :�5�� : �E1. R€ � Ef"Cw ,�.sJ.;� _�� - l�C� � . �6. � <br />BILL 'f`OEWIROSER "WEAR PRO PER, P PE <br />14. GENERATOR'S CERTIFICATION: I certify the materials described above on this manifest are not subject to federal regulations for•reporting proper spos I of Hazardous Waste. <br />Generator <br />Offerors Printed/Typed Name Signature ,: /'��- Month Day Year <br />j <br />15. International Shipments <br />ElImport to U.S. ElExport from U.S. Port of entry/exit: <br />z <br />_ — <br />Trans orter Signature for exports only): , 1TWe leavin U.S.: <br />cc <br />'. <br />16. Transporter Acknowledgment of Receipt of MaterialsuJ <br />cc <br />Tran ort r1 ri ed/f Nia'lme(�(� S' to Month Da Year <br />y <br />Z <br />Transporter 2 PrintedlTyped Name Signature Month Day Year <br />H <br />17. Discrepancy <br />17a. Discrepancy Indication Space <br />❑ Quantify El Type ❑Residue ❑Partial Rejection E] Full Rejection <br />Manifest Reference Number: <br />17b. Alternate Facility (or Generator) U.S. EPA ID Number <br />J <br />U <br />LL <br />Facility s Phone: <br />w <br />17c. Signature of Alternate Facility (or Generator) Month Day Year <br />Q <br />2 <br />D <br />. <br />18. Designated Facility Owner or Operator. Certification of receipt of materials covered by the manifest except as noted in Item 17a <br />Printed/iyped Name Signature Month Day Year <br />169-BLC-0 6 10498 (Rev. 8106) COPY <br />