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A <br /> NHS W.14 <br /> `Ma.o <br /> ' Generator 10 Number _._._ 2.Page 1 of 3.Em <br /> NON•HALlR000S ergancy Response Phone �4.Waste Tracking Number <br /> WASTE MANIFEST C A L 0 0 0 3 8 7 9 2 0 1 800 424-9300 O-eViIFE t <br /> G to's Name and Address GeneraWa Site ArfMesa(f ditlennt Than math addmsI <br /> HTRZOG TRAIT SERVICES INC HERZOG TRANSIT SERVICES INC <br /> 1020 E ALPINE AVE A200 1020 E.ALPINE AVE <br /> STOCKTON CA 95204 STOCKTON CA 95204 <br /> �Generator'sPhow 816 <br /> 6 Transponer I Company Name US EPA 10 Number <br /> FREMOUIW ENVIRONMENTAL SERVICES INC C A R 0 0 0 1 7 1 0 1 7 <br /> 7,Transpo^ter 2 Company Name US EPA 10 Nunbe: -- <br /> --- --�------- <br /> NomHILLS La end SiteANDFwd��ILL,INC. umber U S EPA 10 N <br /> PDTRER� <br /> 3675 POTRERO HILLS LANE <br /> SUISUN CA 94585 <br /> Faek a P1bne 707 <br /> 10.containers 11.Tolaf j 1_2.Unit <br /> .9 Waste Snipping Name and Descnptbn -__ � <br /> rNo. Type ouarTtity Wt'vol. <br /> e NON-HAZARDOUS WASTE,SOLID(OIL IMPACTED SOIL 8 <br /> ROCK) ` !• ! i \/ <br /> rc� J <br /> lr9r <br /> a <br /> 3 I � <br /> 1 <br /> -- <br /> 3 a, I <br /> e j , <br /> 13.Speoal Hand N lrovuctions and Ad66ona!Infonna:icn ------------- _. -._ <br /> 1)PHLF—jt_L Non Hoz Soi!/Rock(ana"cal provided to disposal facility) <br /> U@( <br /> .GERATOR'SIOFFEROR'S CERTIFICATION:I ieraby declare that the tbntencv of this eonslp^mene era fully and accurately described above by the .1 shlppi g name.and are classified,packaged, <br /> marked and labal ed'pklcanled.and are In all respects in proper condition br ssansport according to Ipplkabie rrlternsuonai end rt0tfbrai goverruvau reguatim. <br /> Gena ataprs/l�Onerora Prirted7yood Name -Xt1i t AQP 1ZAnTF'--M 3 i Signa ure KPTl p^ T7 7- Month Day Year <br /> Sh -_ —.—1 r' 1,-7 I b <br /> tn!emationat hiprments 0 <br /> G ❑Import to U 5 ❑Export I-am U.S. Pon of entryre.:t: <br /> T uc;ner Se ratue IIOr ec'w�rU onir�:---__ .... Dale leaving US: <br /> ---- -------- <br /> e 16.T ran9poner Acknowledgmem of Receipt of Materials <br /> g Tran}sponte'1 PnntTed Nar-e --- Signature Month Day year <br /> Transporter 2 Pr d'yped Nam Month Day Year <br /> 17.Discrepancy - <br /> I' <br /> +7a Discrepancy Indication Som <br /> 01:1 ----- <br /> I uardity Type ❑Residue ❑Pa.tial Rejection ❑Full Rgacbm <br /> Manifest Reterence Number t <br /> ;a l"bAllemafe Fecliy for Ganerarcrl��--,— U.S.EPA ID Number <br /> CJ ' <br /> I.-FacAt,'s Phone: _ <br /> - <br /> 1% Signature of Aaemate Facky,for Generator) - -- Month Day Year <br /> iB DiniVated Fadsry Owner or Ow"Consficatbn o'receipt of materials covered by the manifest except as noted in Item 17a — <br /> PrkkedrTyped Name Signature Mprdh Day Year <br /> 169-BLC-0 5 11977(Rev.9109) DESIGNATED FACILITY TO GENERATOR <br />