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NON-HAZARDOUS 1,Generator f0 Number 2,Page 1 of 3.Emergency Response Phone 4.Waste Tracking Number <br /> WASTE MANIFEST N OT R E Q U I R E D 1 888423-SM 4DD4D-4$4)02 <br /> 5.Generator's Name and Mailing Address Generator's Site Address(if different than mailing address) <br /> 7-EW~ 7-EIf1VM SWfi No.8201M <br /> P.O.Box 711.081111111116 TX 75M 4W Da Vlrfld OF.,Sbekbn,CA 95207 <br /> Generator's Phone' 82S-65W I <br /> 8.Transpo er t Cfo y Na e U.S.EPA ID Ntimher <br /> NOT REQUIRED <br /> 7.Transporter 2 Com Name U.S.EPA 11)Number <br /> B.Designated Facility Name and Site Address U.S.EPA Iq Number <br /> Male CDRuCiWm-Pofkefcr Hlr Lan= <br /> 3675 Polka H&L ww,Sulfa.CA 94585 NOT REQUIRED <br /> Facility's Phone: (M)9149-9451 <br /> B.Waste Shipping Name and Description 10.Containers 11,Total 12,Unit <br /> No. Type Quantity Wt.NoI, <br /> 1. <br /> rt <br /> Q <br /> Noris HuNdow wide.SM(fte 00i D T 10 Y <br /> Ir <br /> z 2. <br /> LLr <br /> c� <br /> s. <br /> a. , <br /> 13.Special Handling Instructions and Additional Information <br /> Sol:99-100% PrO M No: PHF 204M <br /> Dabft O-1% <br /> WVew appfopfi de PPE when hfflldfg of as F&gWF&d byte TSW PMjw w.4ww <br /> 14.GENERATOR'SIOFFEROR'5 CERTIFICATION:I hereby declare that the Contents of this ransignment are fully and accurately described above by the proper stripping name,and are classified,packaged, <br /> marked and Iabeled'placarded,and are in all respects in proper condition for transport according to applicable international and national govemmenfal regulations. <br /> Generator's <br /> behaVoMmmilix f1L1LVqk;k,)40C0jWk6M(jU#L'VAL jj#nVt4UM) More Day Year <br /> _j 15.Intema"W Shipments <br /> Impart to U.S. Export from U.S. Part of entryiexit <br /> —I Transporter Signature for exports only): Dale leaving U.S.: <br /> w 16-Transporter Acknowledgment of Receipt of Materlals <br /> Transporter 1 'ntedlTyped e-zo VQ� Signator Month Aay Year <br /> O <br /> a <br /> N <br /> z Transpor r 2 Pr ®d e N Sig Month ay r <br /> t- <br /> 17.Discrepancy <br /> 17a.Discrepancy Indication Space ❑Qua tv ❑Type ❑Residue ❑Partial Rejection ❑Full Rejection <br /> Manifest Reference Number: <br /> 17b.Alta male Facility(or Generator) U.S.EPA ID Number <br /> J <br /> U <br /> c¢i Facility's Phone' <br /> i7c.Signature of Alternate Facility(or Generators Moretti Day Year <br /> C7 <br /> t!1 <br /> W <br /> O <br /> 18-Designated Facility Owner or Operator Geoftation o e of materials covered by the manifest except as noted in Item 17a <br /> PdntedfFyped Name Signature 11h aaYj., <br /> f fig-BLC-O 5 11977(Rev.9109) dESIGNATED FACILITY TQ GENERATOR <br />