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;0NS=MAt41FJEST <br /> 0US 1.Ganaralor l0 Number 2 Pepe 1 of 3,Emergency Rasponsa Phan 4.Waste Track]7 Numer NIA 1 (877)2 58266 1/-16039-004 <br /> F ag 5c,CtWaln',7i Addcess Generato(s Ste Address{it different Inert malting addrms, <br /> 3028 Na vyDrive <br /> Stockton. CA 95200 <br /> Generator s Phone —W (209)851-4090 <br /> 6 Transporter 1 Corr pary Nome -- -- <br /> Ponder Environmerltai Services I nc a S.EPA!n Nunn r <br /> CAROW 180737 <br /> 7.--.nsporter 2 Company Name <br /> U.S.EPA 10 Number <br /> �F7r1 E5��t7(Tilf U.S.EPA 10 Number <br /> 3875 Potrero HIS Ln <br /> Suisun City, CA 94586 <br /> Facilir:'s Phone _ - T (707)432-007.2 CAR000089488 <br /> 9 Waste Shipparg Name and Descdpwri 10.Gantalners 11.%W 12 Umt <br /> No. Type uuantty Wt <br /> 1 �— <br /> Nonhazardous waste, liquid(rinse water) 001 TT G <br /> w <br /> 3 <br /> 13.Special HandIN frslructions and Additional fnlcrmation <br /> Profs a PHLF-17-137 Truck 01, <br /> ,b b##17-16039 <br /> 14.GENERATOR`SIOFFERORIS CERTIFICATION:I hemby dedare that the rodents of this consignment are July and amuratey descrbed above by the proper shipping Hama and are classffied,packaged <br /> marked and Wbaledrplacarded and are In all respects in proper condition for transport scwrding to appflcahla kNematimW and national governmental regulations <br /> C3 ratofsJONeRa a Pdnted/Typed Name _ jure - <br /> �n fri Monln y 1I]ay g YOU <br /> A 6u.� 1S.Inlernatia1al Ship".' <br /> e � O1. f } t I I / <br /> ❑Innporr to U S ❑ apart t� U.. Pon a1 entrylexh: <br /> Tmr s .Aer 4jonalure gar ev�-,P cn!' date WAm U.S <br /> Cc 16.Transporter Acknoxdedgmenl of Receipt of Malenals <br /> Transpart�yped a Sgnatura Montt pay rr Yaw <br /> Q 'frons r 2 PrintedlT �v _ <br /> P yped Name Sinau-r Monti Day Year <br /> 17.Discrepancy <br /> 17a.0kraparcyInd"tianSpace <br /> El oumy <br /> T - ' �Wv ❑Res due <br /> TWO ®Pamal Re*tDn ❑Full Re*tbrr <br /> 17h.Attemale Facilityh a4lest Relerence Number <br /> Facility dor Generator} <br /> — U.S EPA 1b Number - <br /> v <br /> u-I Facility s Phone <br /> 0:T7—c, <br /> ;t7o.Slpnatura of Nlarrmte FacSty(or Generator} '� Month Day Yeas <br /> �. <br /> a <br /> uj — <br /> i8.Designated Faiiy fanner or ator Certikation of racaipl of maieda!s covered by the manifest except as no Irt Item a __ a <br /> Prvrtedlryped Name — Signature — Math 0 Yaar <br /> 169-OLC-05 11977(Rev.9109) DESIGNATED FACILITY TO GENERATOR <br />