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NON-HAZARDOUS T.Generator IU Number JLPagelof 3,Emergency Response Phone 4.Waste Tracking Number <br /> WASTE MANIFEST NOT REQUIRED � 888.423 40040-48-001 <br /> 5.Generator's Name and Mailing Address Generators Site Address{if different than mailing address) <br /> 7-EliAM 7-EW 11.SWO N0. <br /> 0.BOX 711,Des TX 755 4627 De VkW Dr.,Shxftm.CA 961207 <br /> Generator's Phone: M am-am <br /> 6.Transporter 1 Cam "Clame U.S.EPA ID Number <br /> NOT REQUIRED <br /> 7.Transpo er 2 m any N me U.S.EPA ID Number <br /> S.Designated Facility Name and Site Address U.S.EPA ID Number <br /> VAMMc4rVNICIIbm-pwilew Fis Lamm <br /> 3675 P06WO Fie Lar0,SUkM,CA 94686 NOT REQUIRED <br /> Facie 's Phone: WS) <br /> 9.Waste Shipping Name and Description 10.Containers 11.Tolal 12.Unit <br /> No. Type 4uantly Wt.Nol. <br /> 1. <br /> a Non f onfdM IIID,SM(%* 9 0 i D T i Y <br /> W <br /> Lu <br /> x 2 <br /> 3. <br /> 4. <br /> 13.Special Handling lnslructmns and Additional Information <br /> sot 99-10L % Pro1M NG: PKF-2095 <br /> Dobry:4-1'A <br /> V t w approprif b PPE wfhm hanOW or as rKad by the TSDF FWJW Na: <br /> 14.GENERATOR'SfOFFEROR'S CERTIFICATION:I hereby declare that the contents o€this consignment are fully and accurately described above by€he proper shipping name,and are classified,padcaged, <br /> marked and labeled1placarded.and are in all respects in proper condition for transport according to applicable international and nalional governmental regulations. <br /> Generatods f N{;*�on beheff ofGermakir S4 UttVw& Mon h Day Year <br /> _j 15.International ShipmentsD <br /> A�]V <br /> Import to U.S. ❑Export from U.S. Port of entrylexit: <br /> z Trans seer Signature for exports onl : Date leavi U.S.: <br /> cc W 15.Transporter A oMedgment of Receipt of Materials <br /> Tranwirr 1 n tedlTyped Name. Signature Month Da Year <br /> N V 1 <br /> /Ac <br /> 4 Transporter 2 Printed/yped Name signature Month day Y r <br /> 17.Discrepancy <br /> 17a.Discrepancy Indication space fe ❑Full RejecSon <br /> El Quantity 11 Te ❑Residue ❑Partial Re' Ilion <br /> Manifest Reference Number: <br /> 17h,Alternate Facility(or Generator) U.S.EPA ID Number <br /> zi <br /> 0 <br /> 1 Facil!Vs Phone: <br /> 17c.Signature of Alternate Fadlity(or Generator) Month Day Year <br /> a <br /> x <br /> N <br /> W <br /> O <br /> 1 S.Designated Facility Owner or Operator Certifikato of receipt of materials covered by the manifest except as noted in Item 17a <br /> Printed/Typed Name Signature o ear <br /> 169-BLC-05 11977(Rev.9149) DESIGNATED FACILI TO GENERATOR <br />