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NON-HAZARDOUS 1,Generator ID Number 2.Page 1 of 3.Emergency Response Phone 4,Waste Tracking Number <br /> WASTE MANIFEST NOT REQUIRED 1 885-4234KM 4004048 4)08 <br /> 5.Generator's Name and Mailing Address Generator's Site Address{if different than mailing address) <br /> 7-E%V4 ! 7-EM 40 SbN No.120M <br /> Ped.Sm 711,DOM= TA 75M 407 N Vlr d Dr.. .CA 96207 <br /> Generator's Phone: CM) <br /> s.Tra�poRar 1 Com an � /l U.S.EPA INO <br /> NOT NREQUIRED <br /> 7.Transp tier Company Name �j .j (_ U.S.EPA 10 Number <br /> a.Designaled Facility Name and Site Address U.S.EPA ID Number <br /> Will Carww*m-Pubell Hfs Lents <br /> 31;76 Potha HNb Lane,SuMrlrrt.CA 9+1M NOT REQUIRED <br /> Facili 's Phone: 4925y IT49-8451 <br /> 9,Waste Shipping Name and Descriplion 10.containers 11.Total 12.Unit <br /> No. Type Quantity Wt.Nol. <br /> 1, <br /> x <br /> a Noris FlWarOM VA11101,SOW[SA 001 D T 10 Y <br /> 2. <br /> c� <br /> 3. <br /> 4. <br /> 13,Special Handling Instructions and AddidonW Information <br /> SO:99-1w% Prto1M No: PHLF-204N5 <br /> VJ&K aPF0Prtb PPE MlhBll 1W1I A "n MFdMd by#1*TSDF ProjW No:40M <br /> 14.GEN ERATOR'SIOFFEROR'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 fntemaltonal and national govemmental regulations. <br /> Generator'a err n i ed Na Ort�GMW �, n lu�_Y_ f��� � Month Da �Year <br /> � <br /> i� l r� tii.J <br /> 15.International Shipments <br /> } Import to U.S. Export from U.S. Port of entrylexil: <br /> ? <br /> Transporter Signature for ex rt8 orrl : Date leaving U.S.: <br /> 16.Transporter Acknowledgment of Receipt of Materials <br /> Transporter 1 P"nWyped Namef ] Signatu y ti M <br /> o ❑a ar <br /> CA <br /> Transporter 2 rintedliyped Name Signature " Month Day Year <br /> 17.Discrepancy <br /> 17a.Discrepancy Indication+Space ❑ t ❑Type ❑Residue E]Partial Reiechon Ll Full Rejection Quanti <br /> Manifest Reference Number: <br /> >- 17b.Altemate Facility(or Generator) U.S.EPA ID Number <br /> J <br /> U <br /> L Faci!!ty's Phone: <br /> LEL31 17c.Signature of Alternate Fatuity for Generator] Month Day Year <br /> a <br /> x <br /> c� <br /> N <br /> lLl <br /> 0 <br /> 18.Designated Facility Owner or Operator:Certific 'on of ipt of malerials covered by the manifest except as noted in lVn 1 a <br /> PrintediTyped Name Signature ❑ y ear <br /> 169-BLC-O 5 11977(Rev.9109) DESIGNATED FACILITY D GENER TOR <br />