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.. . . to <br />lgna ure Month Doty Yeah} <br />3 -BLS -C 5 11979 (Rev. 9/09) TRANSPORTER #1 <br />NON -HAZARDOUS 1. Generator ID Number <br />MANIFEST d ",+ "` = <br />-tWASTE <br />2. Pa -gel ofF3.Emerg­encyRes�pons�e Phone 4. Waste Tracking Number-76^76 <br />? <br />6 6 <br />- �: %- ^ P <br />5. Generator's NameandMailing Address �) r <br />JW4 <br />Generator's Site Address i ff different thin mailing address) <br />0% <br />Generator's Phone: %') (� % - S <br />,_� � ' `. G o ,P <br />6. Transporter 1 Company Name <br />f f <br />U.S. EPA ID Number <br />7. Transporter 2 Company Name <br />U.S. EPA ID Number <br />'. <br />�. APP!JC'A' `? -: <br />B. Designated Facility Name and Site Address <br />U.S. EPA ID Number <br />:'�lLLE, CA 9588? <br />Facili 's Phone: <br />9. Waste Shipping Name and Description <br />10. Containers <br />11. Total <br />12. Unit <br />No. <br />Quantity <br />WtJVoI. <br />° <br />1. <br />1 <br />- �fr,.7_- rC�c�� (rc'r �N <br />(A)CDC) <br />FType <br />,, <br />cc <br />W <br />Z <br />W <br />2. <br />0 <br />3. <br />4. <br />13. Special Handling Instructions and Additional Information <br />14, GENERATOR'S/OFFEROR'S CERTIFICATION: I hereby declare that the contents of <br />this consignment are fully and accurately described above by the proper shipping name, and are classified, packaged, <br />marked and labeled/placarded, and are in all respects in proper condition for transport <br />according to applicable international and national governmental regulations. <br />Generators/Offer&s Printed/Typpg Name <br />Signature /; 'I Month Day Year <br />15. International Shipments <br />❑ Import to U.S. <br />15 <br />❑ Export from U.S. Port <br />z <br />of entry/exit: <br />Transporter Signature for exports only): <br />Date leavin U.S.: <br />L 16. Transporter Acknowledgment of Receipt of Materials <br />= Transporter 1 Printed/Typed Name <br />Signature Month Day Year <br />n <br />- <br />71 <br />L r•� <br />'- Transporter 2 Printed/Typed Name <br />i <br />Signature <br />9 Month Day Year <br />ic <br />17. Discrepancy <br />17a. Discrepancy Indication Space <br />❑ Quantity ❑ Type <br />❑ Residue ❑ Partial Rejection ❑ Full Rejection <br />Manifest Reference Number: <br />17b. Alternate Facility (or Generator) <br />U.S. EPA ID Number <br />i <br />i <br />Facility's Phone: <br />17c. Signature of Alternate Facility (or Generator) <br />Month Day Year <br />18. Designated Facility Owner or Operator: Certification of receipt of materials covered by the manifest except as noted in Item 17a <br />lgna ure Month Doty Yeah} <br />3 -BLS -C 5 11979 (Rev. 9/09) TRANSPORTER #1 <br />