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MG/MANIFEST 1.Shipper's US EPA ID No.(if Applicable) I Document No. 12.page l <br /> I .. Of <br /> and Mailing Adnrus <br /> 1j13 Val Drorvira i�O y <br /> STOCKTON <br /> S CA 9bi:-:'06-4001 <br /> Phone Fi`,- cif r ,0 <br /> jrter 1 Company Name 6. US EPA ID Number A.Transporter's Phone <br /> 8. <br /> -M!0 r <br /> 1=f tont, ,V Name tt I't t um r B.Transporters P-hone <br /> 1 <br /> CAJAN ENV IR.CINMENTAL 78 , <br /> Designated Facility Name and Site Address W T 10. US EPA ID Number C.Facility's Phone <br /> HARFICIRCS (,)F- WILMINC-31-17IN LLC <br /> 173-7 DEW[ 3TREET <br /> WITUNTNIBYTIJIN OR 90744 <br /> I .)J <br /> 11.Shipping Name and Description 12.Containers 13. 14. <br /> 1 Tota! Unit <br /> HM No, Type Quantity Wt/vol <br /> a. UNIT-550 0111L'Rolio 9 <br /> LAIVtRS41. - 50 <br /> b- <br /> S <br /> H <br /> I C. <br /> P <br /> P <br /> E <br /> R 7- <br /> 15.Special Handling Instruction and Additional Information <br /> 3K <br /> I ) F.R G*1 F1,F, <br /> E.4 HR EMEAGENCY TFI ) <br /> kit AUTH AS `AGENT–FOR" BY GIEN TO RF-TAI#-I 9 A R, <br /> DOT/PRFL A. 7740871/ 114,3054 9. G. 0. <br /> A) NOW 0) M P) I <br /> 16a.US DOT HAZARDOUS MATERIALS SHIPPER'S CERTIFICATION: TN3 Is 10 mlory illal liku aLow—mmed materials are property described,pacl(nod,molikod and aboled and are in proper <br /> j k;d <br /> 00ralflion lar Dans K%rtniko cr I Itmt.41pkabl"12giA Uzi, �tai Transpwailm, <br /> PrIntedrTyped Name Month Day year <br /> 16b.NO N-REGULATED SHIPPER'S CERTIFICATION: I certify the materials described above on this form are not subject to federal regulations for Transportation or <br /> • Printed/Typed Name Month Day Year • <br /> T 17.Transporter 1 Acknowledgement of Receipt of Materials <br /> R <br /> A Priptedrryped Name Signature, - month Day Year <br /> N <br /> S <br /> P <br /> 0 18.Trans or r 2 Acknowledgement of Receipt of Materials <br /> R nature Month Day Year <br /> E <br /> R Si <br /> T Printed/Ted Name <br /> 19.Discrepancy Indication Space <br /> IF <br /> A <br /> C <br /> I <br /> L 20.Facility Owner or Operator:Certification of receipt of materials covered by this form except as noted in Item 19. <br /> I <br /> T <br /> Printed/Typed Name Signature Month Day Year <br /> llvt :11 rl <br /> I <br /> 111111liqll 1111pi <br /> GENERATOR'S COPY FORM NO.01-90291 (03/2015) <br />