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NON-HAZARDOUS SPECIAL WASTE MANIFEST <br /> No. /4F020Z00 <br /> Section I GENERATOR(Generator completes all of Section 1) <br /> a. Generator Name: �j�Lcb. Generator Location: S,44-jc- <br /> c. Address: 2Z2Ahn f-2�OG12,J,Q0ST d. Address: <br /> S'%OC,,C 7,7A1. CA <br /> e. Phone No.: f. Phone No.: <br /> i'Owner of generating facility diners from the generator,provide: <br /> g Owners Name: h. Owner's Phone II <br /> I. IWM WASTE CODE: <br /> 1 Z DM-METAL DRUMS T•TRUCK <br /> DP-PLASTiCDRUM O-OTHER <br /> j. <br /> Description of Waste: �y����—y S' k. ouanffty Units No. Type <br /> 6M6— �/t �CL�yc`�n�G� ® ® YCU <br /> YL-CUYAtiDs <br /> O-OTHER <br /> Section II TRANSPORTER <br /> TRANSPORTER TRANSPORTER II <br /> a. Name: / vM N a. Name: <br /> b. Address: c?5-0 AM CS 4V F /-J 1A <br /> b. Address: <br /> 'TAS, CA <br /> c. Driver Name: gl� c. Driver Name: <br /> Printr type <br /> d. Phone No.: � y Truck No.: /c7 d. Phone No.: PrinNrype <br /> f. Vehicle License NoJState: e. Truck No.: <br /> f. Vehicle License NoJState: <br /> Acv*wledgement of Receipt of Materials. <br /> Advawledgement of Receipt of Materials. <br /> 91Z 0 't 0 0 g. <br /> Dever Signature <br /> Date Driver SignahJre Date <br /> Section III DESTINATION <br /> a. Site Name: A-10SCO V 1 'TZ FO x IOE FAL..S' b. Phone No.: <br /> c. Physical Address: 4:nc10 OAK.r: NtjD RL) d. Mailing Address: <br /> '-,FAN JOJt > CA <br /> e. Discrepancy Indication Space: <br /> I hereby certify that the above named material has been delivered to the above named facility <br /> f. _ `� ergo the best of mY knowledge the ioregom is true and accurate. <br /> Print Name of Authortred Agent Signature_01— <br /> p L O <br /> Date <br /> IWM-SoUDisposal Form Revised: 14 December tga4 <br />