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NON-HAZARDOUS 1.Generator ID Number 2.Page 1 of 3.Emergency Response Phone 4.Waste Tncldng Number a7®2711 <br /> WASTE MANIFEST NOY RE(A)RM 1 888-423-SW <br /> r L <br /> 5.Generators Name and Mailing Address Generators Site Address(it different dun marling address) <br /> CaMOOR Nlpa COP stw No <br /> 76 BroqdyAw,sac a mft CA.MIS 3505 NaW anus,SWCk&M,CA 85M <br /> Generators Phone: U.S.EPA ID Number <br /> 6.Transporter 1 Company Name CAROM <br /> Ams icon Wap-MM 8 .111M• <br /> U.S.EPA 10 Number <br /> 7.Transporter 2 Company Name <br /> U.S.EPA ID Number <br /> 16W W. i?ifs 81,11"dCJ10 0�D1r3 <br /> LvV Beech,CA.OW13 562-43MW <br /> Fadli 's Phone: <br /> ' 10.Containers 11.Total 12.Unit <br /> 9.Waste Shipping Name and Description Type Qua" WLN01. <br /> ¢ 1. rP fc0 <br /> ' LNcv7-HSM-.a WEVAe:LNOh4 [PU19M&*ff) <br /> w <br /> m 2. <br /> 3. <br /> 4. <br /> ' 13.Special Handling Instmprore and Additional Information <br /> Wee-rn1w ft eQMdPMM MMS&ha W is tit vidUrM,sire <br /> apprWAMW 24 herr emegen W nLua•hm(AMM)4 -&Xi4)VJ8 FarDlla# 27678 1 �j <br /> �►. Pm�ed10: 72OM5.2B <br /> J <br /> 14.GENERATOR'WOFFEROR'S CERTIFICATION:1 hereby declare pat the contents of this consignment are fully and eccurataty descried above by the proper shipping name,and are classified.Padmged <br /> ' <br /> mnaarlkoe�daannfd lllapbaed/ppiLaacaarrded,and are in all respects in proper upon for transport according to applicable thlemaponai and national limmmental regulations.Gere AIS afB OH77a+1 J.&}F1man ""s Month Day Year <br /> 2-211 <br /> .a 15.International SNpmems ❑Import to U.S. ❑Export from U.S. Pod of entry/exic <br /> Transporter Signature for OVOM MIA Dee Wm U.S.: <br /> ¢ 16.Transporter AdonwledgmaN of Repa0t of Materials Month Day Year l <br /> Transporter 1 P' ted!r me SigraWre <br /> 6 I 1 h Da )Year <br /> 7d. Transporter 2 nn Name Signaturey <br /> f <br /> 17.Discrepancy <br /> ' IT na Discrepancy Indication Space ❑Omoty, ❑Type ❑Reside ❑Partial Ra]edion ❑FW Rejection <br /> Manifest Reference Number: <br /> T 176.Alternate Fedlily(or Generator) U.S.EPA 10 Number <br /> ' G <br /> Faa's'ty's Phone: <br /> 17C.Signature of Alternate Facility(or Generator) Month Day Year <br /> a <br /> 1 m <br /> 0 <br /> w <br /> GC' <br /> 16.Designated Facility Owner or Operator.Cediraation of receipt ol materials covered by the manifest except as rated in Item 17a _ -- <br /> PdRtedR r Sign@Me MoJ F R7!M -Day 'Yare <br /> IL y �. l <br /> TRANSPORTER#1 <br /> ' 169-BLC-0 5 11977(Rev.9109) <br />