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NON-HAZARDOUS 1 1.Gewrotor ID Number 2.Page 1 of 3.Emergency Response Phone 4.Waste Tracking Number <br /> WASTE MANIFEST NOT REQUIRED i 8084234KW 40040-454006 <br /> 5.Ganerator s Name and Mailing Address Generator's Site Address(if different than mailing address) <br /> 7-Ehr#W 7-EN'W SM No. <br /> R.O.Box 711.Dt&US TX 75M 41 7 Dry Vbd Dr.,S1ockhm,CA 9&W <br /> Generator's Phone: <br /> 6.Transporter 1 C p ] *" U.S.EPA ID Number <br /> /II./► NOT REQUIRED <br /> 7.Transporter 2 Cam any Name U.S.EPA ID Number <br /> 8.Designated facility Name and Site Address U.S.EPA ID Number <br /> VAtab ConrocGom-Pokwo f1k LmN <br /> 3675 Porro HNs Lana*Suisun,CA 94585 NOT REQUIRED <br /> Facili 's Phone; <br /> 9.Waste Shipping Name ancr. 1 Q.Containers 11.Total 12.Unit <br /> No, Type Quantity WI.NoI. <br /> t. <br /> cc <br /> a Neon Huardous:VMM,S*d(So*) 9 0 i D T f Y <br /> W <br /> w <br /> c� <br /> a. <br /> 13.Special Handling Instructions and Additional Information <br /> Sol:99-iDD% Pn)ft No: PHLF-204195 <br /> DobrW D-I% <br /> VAw app im prbb PPE when isandbi g or as FogLird by the T=F Pmod No:40M <br /> 14.GENERATOR'SIOFFEROR'S CERTIFICATION:t hereby declare the[the contents ol 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!or transport according to applicable international and national govemmentst regulations. <br /> Genera[orslA"MRJ'" of CWWFAW � ,� (d LAwwm4,lm) Month Da Year <br /> l <br /> 15.International Shipments ❑import to U.S. ❑Export from U.S. Port of errlry/axil: <br /> z Transporter St nature for ex orfs an : Date leaving U.S.: <br /> ¢ 16.Transporter Acknowledgment of Recelpt of Materials <br /> e Transported P edlTypad Name t Signature Month Day Year <br /> � t <br /> U) / ' <br /> Transporter 2Phnfe&Typed Na0ie Signature lay <br /> rr <br /> t- <br /> 17.Discrepa <br /> 17a.11 screpancy indication Space <br /> ❑Quantify Type ❑Residue ani ejection ❑Ful!Rejection <br /> Manifest Reference Number: <br /> 17b..Affemate Facility(or Generator) U.S.EPA ID Number <br /> J <br /> U <br /> LL Facility's Phone: <br /> 17c.Signature of Alto mate Fadlity(or Generator) Month Day Year <br /> a <br /> z <br /> wW <br /> G <br /> 18.Designated Facility Owner or Operator:Cert-cati receipt of materials covered by the manifest except as noted in Item 17a <br /> Printedi Typed Name S) �) ignatury sa <br /> 169-BLC-0 5 11977(Rev.9109) 1 V "., DESIGNATED FACILITY O GENERA OR <br />