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) <br /> 1 1.Generator ID Number 2.Page 1 of 3.Emergency Response Phone /.Waste Tracking Number <br /> NON-HAZARDOUS c t r�- �la.E:-.it;'3»?r4:GEct . <br /> WASTE MANIFEST 'U'j-'1''3''wr. <br /> 5.Generatcfs Name and Mailing Address Generator's Sita Address(if different than mailing ardressl <br /> s (F' <br /> 10,57 L;=ARM �;F;sru,Tx �iGKaG <br /> cJU r:!err RW: <br /> l. _'rv.i,L 95377' l,'Sy5` );zA`-, .,r+4r ,_., <br /> GeneralofePllone.' '`1f=�i1.A3 <br /> U.S:EPA ID Number <br /> B.TmnspoM(1 Company Name _ <br /> �y <br /> AU V4 <br /> U.S.EPA ID Number <br /> 7.Transporter 2 Company Name <br /> U.S.EPA ID Number <br /> B.Designated Facility Name and Site Address PF,TIRER0 HILLS L%kN FILL fi;C' <br /> 3875 r13TRE;rJ HILI...S LANE <br /> SUSUN,CA 9452,51 USA <br /> Fad6b c Phone: <br /> 10.Containers 11.Total 12.Unit <br /> 9.Waste Shipping Name and Description :: No.. Tll of,dity I WTbI. <br /> 210 .. <br /> 0 <br /> a . <br /> ¢ <br /> w : <br /> cti <br /> 3. <br /> r" <br /> a. ¢' <br /> 13.Special Handling Instrumons and Additional Information. _ - <br /> IJG`i.J+_' 3Rr92-QJJ3- ._ <br /> 14.GENERATOR'StOFFEROWS CERTIFICATION:I hereby declare that the contents of this consignment are NIIy and accurately described above by the proper shipping name,and are dassified,peol ged, <br /> marked and IabeleNplacarded,and are in all respects in proper condition for transport according to applicable international and natlonal mmental regulatarrs. Month Day Year- <br /> GeneratoVslOnerots PnntedlFyped Name - Signature <br /> A }- UG <br /> `�.1 �'C(3 i'1'4- -�•'"-,� 1 Z. <br /> 15.International Shipments ❑Import to U.S. N tf - ❑Export from U.S. Pont of entry/ext <br /> Tran er Si nature for ex rts on <br /> Date leavln I US.' <br /> 16.Transporter Acknowledgmend of Receipt of Materials -- Month Day Year <br /> Transporter 1 Pr1:A LE'yped Nara,: SignaNre O� -- <br /> Mond Opp-. Year <br /> z Transporter 2 Pdnle ypel Name <br /> Signature <br /> F <br /> 17.Discrepancy <br /> 17a Discrepancy Indr[Mlion Space ❑OuanBty ❑Type ❑Residue ❑Pa mi Rejection ❑Full Refection <br /> merriest Reference Number: <br /> U.B.FPA 1D Number <br /> r 17n.Alternate Facility(or Generator) <br /> u <br /> Facility's Phone: Month Day Year <br /> w 17c.SignaNre of Afternale Fac1iry(or Generator) <br /> a <br /> w <br /> 0 <br /> 18.Designated Faaliry Owner q+er ipr.CentBcetion of receipt matenalsmvered by me manifest except as noted in Item 17a esexp ` dd�^ '� <br /> Signature �jf r 7� <br /> Pnnted/f ed Name (jj _ '� <br /> A Y / <br /> TRA[dSPORTER#t ' <br /> 169-BLC-06 10498( ev.9109) <br />