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r _.._. _.. <br /> NON-HAZARDOUS 1 Ganeralvr ID NumCr r 2 Page t N 3 Emergency Response Phcvie 4.Waete TracMing Numtsar <br /> WASTE MANIFEST 1 �_. <br /> 5 Generator's Name arxi Melling Address .Al:t.Ed FrrititpsGerreraler's Sile Address(if dillerenl Than mitiftoften) <br /> BIJSF Railvvav Cc) BNSF Railway Cri <br /> 7,40 E.Carnal:Iir- Dr MP1119 Track. 137 <br /> San Bernardino CA 82406 Stockton CA 95206 <br /> Generator's Phone <br /> 6.Trans rte(I Ca <br /> W RAY U.S EPA ID Number <br /> Envlronirrental L__owls►tOs_-1nr.-------- —�_1�hZ.._Q_.D. _2 1_ 7 t <br /> 7.Transporter 2 Company Namr _ U.S EPA ID Number <br /> 8,Designated Facirily Name and Site Address — U.S.EPA ID Number <br /> Filter Recycling Setvices,Inc. <br /> 180 W.M onte Avenue <br /> Bloomington CA 92316 <br /> FocQ sPhone' -149-411-.20 <br /> 10 Cunlainers11 Total 12.Unit 2�� <br /> 9.Waste Shipping Name and Description <br /> No. Type ouantity WINol. <br /> 0 1 Non-Hazardous Ukste Solid(Soil) <br /> a 0 <br /> wCM y <br /> z - _ <br /> W <br /> 2. — -- <br /> 13.Special Hari*v Instructions and Additional Inlormation // <br /> 1)(S)Sol rY <br /> cantalinated w.rFrydrfi <br /> acaons N 15041424 Din# P 7-.21,��L WD#8156878 <br /> 1tj3611 -Tu JjS: 1a1. 1,a_ -- — - <br /> 14.GENERATOR'S/OFFEROR'S CERTIFICATION:I hereby declare that the contents of this wnsignmeni are fully, ralaly desaibed soove by the proper shipping name,and are classilied,packaged, <br /> marked and lebeledlplacarded,and aw In an respects in proper condition for transport according to applicable k and national govemmental regulations. <br /> t NOlferdfs Pi* Name Sig_tu Monlh Day Year <br /> J 15.Irsanollotral <br /> Import to U.S. ElE t U.S Port of entry/exit: <br /> Tra xmr&yrratwo(tor exports ar'14' _._ Date loaft U.S: <br /> 16.Transporter Acknowledgment of Receipt of Materiels <br /> T%Li eP~1 F'rkM`od/lYPod // Si" <br /> v _4___Z_-- — — hbnth Day Year <br /> a(xlrorlar 2 Purrrtkk�ti Sdd�rtdriiTTyped Name torture1 <br /> 9l Manih Day Year <br /> 17.Discrepancy -- -- ( <br /> 179-Discrepancy Indication Space <br /> ❑Ouantily ❑Type ❑Residue ❑Partial Rejection ❑Full Rejection <br /> _._ Mantles(Reference Number _ <br /> 17b.Altemale Facddy(or Generator) U.S EPA ID Number <br /> J <br /> U <br /> tai Fadbt)(s Plane: , <br /> 17c.Signature of Alternate Facility(or Generator) Month—Day Year <br /> yz <br /> n <br /> � 1 <br /> 18 Designated Facility Owner or Operator Certifltation of recelpl of materials covered by the manifest except a d In Item 17a <br /> Printed/Typed Nan -- e h Oa Y <br /> 169-BLC-0 5 11977(Rev.9/09) DESIGNATED FACILITY TO GENERATOR <br />