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•/Y <br /> - - - - - <br /> j <br /> NON-HAZARD <br /> OUS 1•Generator 0 Number 2 Page 1:6f 3 Emergency Response Phone 4.Waste.TracKing Number <br /> WASTE MANIFEST 'Clip 4r) pg-5607 4241-N <br /> 5,GeneratDes Name and,MdOng Address Generator's Slte,Address(If different than mailing address) <br /> :J-1if le I AeS tas't,1 r,=arr3- Af� "mo520� i :�a.J <br /> (323) 25 -4 zyt540 <br /> Generator's Phone: - ' <br /> 6.Transporter i Company.Name U.S.EPA ID Number - <br /> 7.Transporter 2 Company Name. U.S.EPA ID Number - <br /> 6.Designated Facility Name and Site Address U.S,EPA1D Number <br /> �C3d run'1&4q• L ,+ <br /> #C'N : . 3 7 . € 1 f �i3�-1`; � ' 1)00' 220 .33 <br /> Facil' 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 Cf any)) No Type Quantity. WElvol. <br /> y <br /> Z 2 <br /> w. <br /> 3, : <br /> sp g ., <br /> t3.. ectal Handling Instructions and Additional Information <br /> r c <br /> 14.GENERATOR'S CERTIFICATION:I certify the materials,described above on this manifest are,not subject to federel regulations for reporting proper disposal of Hazardous Waste ' <br /> Generator slOfferor s P.nn yped Name _ Signature f Month Da Ye <br /> 15,Intern Shipments " <br /> ❑Import to U.S- ❑Export k:Pod of entry exit: <br /> F 4rom U S on* <br /> &t <br /> odor Si nature fors rts on Date leavingU.S. <br /> i <br /> tic 16.Transporter A6novdedgrnent of Receipt of Materials <br /> Trans9ortet ;Primadliyp N Signaiure�' ` �.: Month - . aye Y <br /> f } <br /> f ! - <br /> ., .. <br /> t' _ <br /> 06 A <br /> Z Transporter 2 PrintedlTyped N 'e Signature Month . Day Year i <br /> F. <br /> 17.Discrepancy . <br /> 17a.viscrepancy Indication Space, r l ❑Panlal Re ecbon ❑'Full Fle]ecSion <br /> ❑Quantity. ❑Type. Residue ] <br /> Meanitest Reference Number.' <br /> 17b.Attemate Facility(or Generator) U:S.EPA ID Number <br /> Facilitys Phone: <br /> w 17c.Signature of Alternate Facility(or Generator) . _ Mouth :Day Year <br /> tl1 <br /> a NA <br /> Y�N <br /> f <br /> t & <br /> a <br /> ' i �.�:' ° " r. _ -.� ,. .A i. _ � �r:�, '.f� ..w ,_ i �,�. - � � .a�wYs � '�• `�ia?�s.1!_'. �.,<�`" mac®• <br /> 18.Designated Faoilily Owner or Operator:Cenification:of receipt of hazardous materials covered by the manifest except as noted initem 17a r <br /> Printedllyped Name :. :._ :Signatu <br /> re Manch Day Year <br /> j 169-BLC-0 6 10498 <br />