Laserfiche WebLink
M <br />N <br />01 <br />U <br />y <br />169-BLG0 5 11977 (Rev. 9/09) <br />ttJ�t.:1.�:1.sG1.ti a �� ���� r n.� �ai���.i� �.cr�•�::� <br />NON -HAZARDOUS <br />1. Generator ID Number <br />2. Page 1 of <br />3. Emergency Response Phone <br />4. Waste Tracking Number <br />18-0142 <br />800 424-9300 <br />WASTE MANIFEST <br />Generator's Site Address (a different than mailing address) <br />5. Generator's Name and Mailing Address <br />g y <br />Q esic <br />cuEvRON P Waste Tra Y <br />,; <br />CHEVRON eg y g <br />P_ 0_ T 6004 20811g$ <br />Q g <br />4S , CA 94583 755 S_ BLVD - <br />386-6044 Attn: , CA 95378 <br />Generators <br />GeneratoPs Phone: U.S. EPA ID Number <br />6. Transporter 1 Company Name ADAM S S , I C _ CAM00189431 <br />U.S. EPA ID Number <br />7. Transporter 2 Company Name <br />U.S. EPA ID Number <br />8. Designated Facility Name and Site Address <br />USA LAND RECLANATION/WK <br />1211 _ GLADSTEWE MEET <br />USA, Cil 91702 <br />626 969-1384 <br />Faciii <br />sPhone: <br />10. Containers <br />11. Total <br />12. Unit <br />9. Waste Shipping Name and Description <br />Quantity <br />WtJvol. <br />No <br />Type <br />1 SOLID <br />ay <br />cc <br />` <br />€ISER S/Ss PIPING; P S ; ST. DCERIS <br />P <br />q <br />DT <br />NO <br />, <br />aW ry <br />3.�z <br />4 <br />13 Special Handling Instructions and Additional Information 1) ETBERGLAS S/STEEL PIPING; ME PANS <br />WAR APPROPRIATEPPR <br />PROMCT MANAGER: JON ROLOFT PROFILE #622752CA <br />-RTAN <br />14. GENERATOR'S/OFFEROR'S CERTIFICATION: I hereby declare that the contents of 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 according to applicable international and national governmental regulations. <br />Generatoes/O,ffReror's Pdnted/T ed Name Signature Month Day Ye <br />YDIER ON 15EMW OF CHEVRON -74;> <br />423 425 F <br />15. International ShipmentsImport U.S. ❑ Export from U.S. Port of entry/exit: <br />to <br />Z <br />Transporter Signature for exports only): Date leavin U.S.: <br />cc 16. Transporter Acknowledgment of Receipt of Materials <br />Tran rt Printed/T Signature M Y <br />0-MR1 E" <br />Aw <br />Signature Month Day Ye <br />Transporter Printed/Typed Name <br />a <br />17. Discrepancy <br />17a. Discrepancy Indication Space ❑El Residue ❑ Partial Rejection ElFull Rejection <br />❑ Type <br />Quantity <br />Manifest Reference Number: <br />U.S. EPA ID Number <br />17b. Alternate Facility (or Generator) <br />J <br />v <br />Phone: <br />Facility's Month Day Ye <br />w 17c. Signature of Alternate Facility (or Generator) <br />Q <br />V I yi) (� A9y� �'� ,, 3� Y:; ' ��ILY' ! �".k/���,Ar&o"����C � 4 , AF1i p'i't} `f'.2.�'T'Y F� W �'✓^'�""1 L M•�j'r''�� S <br />wF� �.a �i��.µ fi m 4y :. .. dis # �.-r '��•�. 5 nod . I 4y .' ( k� t �.1 <br />18. Designated Facility Owner or Operator. Certification of receipt of materials covered by the manifest except as noted in Item 17a <br />Signature Month Day YE <br />Printed/Typed Name <br />169-BLG0 5 11977 (Rev. 9/09) <br />ttJ�t.:1.�:1.sG1.ti a �� ���� r n.� �ai���.i� �.cr�•�::� <br />