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I r( <br /> 1.Generator ID Number 2.Page 1 aF 3.Emergency Response Phone 4.Waste,Tracking Number 4 5 5$ <br /> NON-HAZARDOUS I <br /> WASTE MANIFESTCyr ' <br /> Generatafs Sae Address(A different than <br /> ;.Generators Name and Mailing Address mailing address) <br /> 7565 Street <br /> Glover Farrilly Trust Tracy,CA 96378 i <br /> P.O.Box 336,Tracy,CA 95378 <br /> 3enemtofs Phone U.S.EPAID Number <br /> i.Transporter 1 Company Name CAR=148338 <br /> American Integrated Services.Inc' U.S.EPA ID Number i <br /> 7.7rensporter 2 Company Name <br /> i <br /> U.S.EPA 1D Number <br /> 8.Desjgrated�liHHis awnndAdress <br /> F�i� NOTREQUIRED � ,) <br /> 3675 Potrero Hills Lane <br /> Suis>Im.9A 94585 y, <br /> Facility's Plane: I rr <br /> 10.Containers qTo1a112,,UnI,1 } <br /> 9a. 9b.U.S.DOT Description(including Proper Shipping Name) NO. Type <br /> 1 DM . <br /> Nor:-Hazardous Waste Sorld(Soil) „(�� TM <br /> 2. <br /> .Y,*. <br /> t. <br /> { l <br /> 4. <br /> I <br /> 13.Special Handling Instructions and Additional Information Prom dsi PHLF11058 <br /> Wear level D PPE whtla handling. WsigW or volumes are Project#: 74026-7-22 <br /> approximate. 24 hour emergency number(888)42$MW �} <br /> 14.GENERATOR`S CERTIRCATION:I cerlily the materials described above on this manifest are not subject to federal r u tions for r roper disposal of Hazardous Waste. Month Day YM <br /> GeneratofslOfferofs Printed!! d Name !9 re <br /> 17 <br /> 15.International Shipments ❑ ElExport fro U. Port of entryle*. <br /> Transporter Signature(for exports only): Import to U.S. Date leaving U.S.: 1 <br /> I <br /> 16.Tmnsporter AcknoWedgement of Receipt of Materials signature Month Day Year ' <br /> Transporter 1 Printedrryped Nme <br /> ' Q t�CQ ATl C <br /> °•' � Signature Manch Day Year �•• <br /> ( Transporter 2 P 76 yp. Name <br /> .17,Discrepancy <br /> t ,17a t <br /> Dscrb ancy Indication Space ❑Tye Residue❑ ❑Paftl Rejection Full Rejection i <br /> -h'(•, ,.�s. ❑Quantity ` <br /> i <br /> •• �• " '' ':f'�-: ;` <br /> Manifest ReferenceNumber, <br /> : •'1'• <br /> U.S.EPA 1D Number <br /> r 17b.A1tetnate Facility(or Generator) <br /> 4 facdi 's Pione: Month Day Year, <br /> r <br /> � 17a S'syhalure of'Altemate Facifay(or Generator) <br /> Li t <br /> z777777777= <br /> ? t � F t� ''"� i n k}r.;x -Ili , 't U?tt_ pia t tZ rp rl ''.•.�t � ?. .x 'v f {'} S�+ ti�'', 1-. <br /> 18.Designated Facility Owner o pe t Certification of receipt of materials covered by lie manifest except as noted In item 7 <br /> If3 Jay <br /> Signature ear <br /> Pdnledltyped Name <br /> 169-BLGO 5 11977(Rev.9109)' ESIGNATED FACILITY' GENERATO <br />