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Please print or type.(Form designed for use on elite(12-pitch)typewriter.) <br /> TNONHAZARDOUS 1.Generator ID Number 2.Page 1 of 3.Emergency Response Phone 4.Waste Tracking Number <br /> WASTE MANIFEST !CAJ 103W233 <br /> S.Generator's Name and Mailing Address Generators Site Address(if different than mailing a dress) <br /> Sit• T LOOSTRI (GNTWAY) <br /> 9S 8186iiTE RD. <br /> TRA. .* ,CA V377 <br /> Generator's Phone: <br /> 6.Transporter 1 Company am, U.S.EPA ID Number <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> '4oj FS T • 'al&? shn-in e LVC KIDEOW I MIR <br /> 8.Designated Facility Name and Site Address U.S.EPA ID Number <br /> OUA FS TES, C . 0I YHe E',:LL <br /> AZ IVNA3 <br /> Facilites Phone: x.12-231.2 ' <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 /> 1. <br /> z. 1,"VE 4l. -TIF LAMPS- .fie-t T RE JIATE <br /> COMPACT LA � -zo eA � <br /> 3. <br /> 4. <br /> 3.Special Handling Instructions and Additional Information <br /> FVC-4-l1 E ECW ALL <br /> LORS CM9702 <br /> P <br /> 14. GENERATOR'S CERTIFICATION: I certify the materials described above on this manifest are not subject to federal regulations for reportingproper di osal of Hazardous Waste. <br /> Generators/Off ores Pnnted/Typed Name Signature / Month Day Year <br /> ILt, <br /> .r 15.International Shipments <br /> h- ❑Import to U.S. ❑Export from U.S. j Port of entry/exit: <br /> Transporter signature(for exports only): Date leaving U.S.: <br /> w 16.Transporter Acknowledgment of Receipt of Materials <br /> Transporter 1 PrintedlTyped,Name t Signature « Mo. h Day Year <br /> O <br /> Transporter 2 Printed/Typed Name Signature Month Day Year <br /> t—, <br /> 17.Discrepancy <br /> 17a.Discrepancy Indication Space ❑ QuantityType ❑Residue <br /> ❑ yp El Partial Rejection El Full Rejection <br /> Manifest Reference Number: <br /> 17b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> J <br /> U <br /> W Facility's Phone: <br /> w 17c.Signature of Alternate Facility(or Generator) Month Day Year <br /> Q <br /> Z <br /> C� <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-GENERATnR't4INITIAI rnPV <br />