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NdlFHAZARDOUS 1.Generator ID Number 2.Page 1 bf 3.Emergency Response Phone '" :.. .4.Waste Tracking Number <br /> WASTE MANIFEST. '- ? 'a <br /> S.Generator's Name and Mailing Address Generator's Site Addrass'(if different than mailing address) <br /> •r 3 ti, <br /> CA I <br /> Generator's Phone: <br /> 6,Transporter 1 Company Name U.S.EPA ID Number <br /> ~ <br /> 7.Transporter 2 Company Name1. U.S.EPA ID Number <br /> 8,Designated Facility Name and Site Address U.S.EPA I.D Number <br /> t :nf; ��+ rxa °1sM� <br /> ?SID ,A. 3r"lal is r <br /> ;3a c:i11,1, CA 93 13 7 37-11 3i7 190 221 39:3 <br /> Facifl s Phone: <br /> 9a. 9b,U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit <br /> HM and Packing Group(if any)) No. Type Quantity WtJVol. <br /> m 2. <br /> 3. <br /> 4. tt <br /> 13. Special Handling Instruclicns.and:Additional Information <br /> 14.GENERATOR'S CERTIFICATION:I certify the materials described above on this manifest are not subject to federal regulations for-reporting proper disposal of Hazardous Waste. <br /> Generator's(Off roc's PrintedAped Name Signature �s J Mo Ye4L. <br /> t t -'��in <br /> 15.International Shipments ❑'Import to U.S. ❑Export from U.S. Port of entry/exit: <br /> Transporter SinatureSore rtson : Dateleavin U.S.: <br /> cc 16.Transporter Acknowledgment of Receipt of Materials <br /> Transp0.dbr,4 PdgtVN, d N e .7 Signature � a r }M1on<�h/T Day L. Y}e <br /> Z Transporter2lPrintedffypedhlarfia Signature Month Day Year <br /> 17.Discrepancy <br /> 17a.Discrepancy Indication Space ❑Fuli Re' <br /> ❑Quantity ❑Type ❑Residue, ❑Partial Rejection fee' I <br /> Manifest Reference Number. <br /> 17b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> x, <br /> U <br /> uQ Facility's Phone: <br /> LOU 17c.Signature of Alternate Facility(or Generator) Month Day Year <br /> 4 <br /> 41 <br /> h <br /> W „ <br /> Q � E &' ins s a,• ��',� �'y `� � x. r' '''"�� �� - �' , <br /> c <br /> 16.Designated Facility OwnerorOperator.Certification of receipt of hazardous materiafs covered by the manifest except as noted in Item 17a <br /> Printed/Typed Name Signature Month Day Year <br /> 189-SLC-0 6 10498 GENERATOR'S/SHIPPER'S INITIAL COPY : <br />