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Please print or type.(Form designed for use on elite(12-pitch)typewriter.) <br /> NON-HAZARDOUS 1.Generator'ID Number 2.Page 1 of 3.Emergency Response Phone 4.Waste Tracking Number <br /> WASTE MANIFEST CAL02M, 1209-8,'49-dW 03,2q#I <br /> S.Generator's Name and Mailing Address Generator's Site Address(if different than mailing address) <br /> f LC`i=CAa"a ICS,( E .MI) <br /> low WEBI-SCKME RD <br /> TRACY,CA W-371 <br /> Generator's Phone: ft_ %. i <br /> 6.Transporter 1 Company Name U.S.EPA ID Number <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> 8.Designated Facility Name and Site Address U.S.EPA ID Number <br /> 57"6 fid.JEFFERSON ST. 00001,37 r <br /> PHC 4X,It 85043 <br /> Facility's Phone`602`1' S �. <br /> 9a 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit <br /> HM and Packing Group(if any)) No, Type Quantity Wt.Nol. <br /> o Ufcv 3 Wa%W.Wad Mom,rtnstt'il ed <br /> 2. Lftum Betbories.9,043 <br /> Unp vma#Waste imp <br /> 3. SWeries.dfy,twrw«DOT ie s! ° <br /> IetT9§fid A1}ta1i1 <br /> 4. <br /> 3.Special Handling Instructions and Additional Information <br /> W14 <br /> 14. GENERATOR'S CERTIFICATION: 1 certify the materials described above on this manifest are not subject to federal regulations for reporting proper disposal of yazardous Waste. <br /> Gerlerat r'slOfferor's Printed/Typed Name Sign dre; Month Day Year <br /> 1• i � i t � f•i•�,o 4. t � 5' (.:::'t ! - is 1,..., d✓ b-'1 <br /> 15.International Shipments <br /> H ❑Import to U.S. ❑Export from U.S. Port of entrylexit: <br /> z Transporter signature(for exports only): Date leaving U.S.: <br /> W16.Transporter Acknowledgment of Receipt of Materials <br /> Transporter rinted/Typed Nap Signature Month Day Year <br /> 13 11'/ 1// <br /> Transporter 2 Printed(Typed Name Signatu Month Day Year <br /> F- <br /> 17.Discrepancy <br /> 17a.Discrepancy Indication Space ❑ Quantityyp <br /> ❑Type ❑Residue ❑Partial Rejection ❑Full Rejection <br /> Manifest Reference Number: <br /> h 17b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> J <br /> U <br /> Facility's Phone: ' <br /> w 17c.Signature of Alternate Facility(or Generator) Month Day Year <br /> a <br /> z <br /> t� <br /> 18.Designated Facility Owner or Operator:Certification of receipt of materials covered by the manifest except as noted in Item 17a <br /> Printed/Typed Name Signature Month Day Year <br /> 6-NHM-C-C-11 <br /> 6-GENERATOR'S INITIAL COPY <br />