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NON-KAZARDOU5 1 1.Generator ID Number 2.Page 1 of 3-Emergency Response Phone 4.Waste Tracking Number <br /> WASTE MANIFEST NOT REQUIRED 1 88842348060 4OD+1a4"2 <br /> 5.Generator s Name and Mailing Address Generator's Site Address(if different than mailing add res <br /> 7-EMwn 7-ENwrt Sbn NO.SWIM <br /> P.D.Box 711,Defte TX 7 21 47 Da VW Dr..Slac*lrm CA 9'=7 <br /> Generator's Phone (M) <br /> fi.TransporteSkI <br /> ny Name �"' � U.S.EPA I[]Number <br /> NOT REQUIRED <br /> 7.Transporter 2 Compan Name U.S.EPA ID Number <br /> 8.Designated Facility Name and Site Address U.S.EPA If)Number <br /> 1114111111111111111111 canirwellon-plobwo Iii►1.en100 <br /> 3675 POO H1k Lan*.SUW^CA 9+1686 NOT REQUIRED <br /> Fatal' s Phone: MM 1 <br /> I Waste Shipping Name and Description 10-Containers 11.Total 12.Unit <br /> No- Type ouantity WtNOI. <br /> Ir <br /> 1, <br /> Noll kMidim valft.Sold[Sm 00i DT '10 Y <br /> x <br /> w <br /> z 2, <br /> w <br /> c� <br /> 3- <br /> 4- <br /> 13-Special Handling Inslruaons and Additional Information <br /> so&99-100% PMM W. PMF Z04M <br /> VJ9W approprlrHa WE WhM lranSM or as re p*ed by the TSDF Pmol No,40M <br /> 14.GENERATOR'S/OFFEROR'S CERTiFICAT(ft I hereby declare that the contents of this consignment are fully and accurately described above by the proper shipping narne,and are classified.packaged. <br /> marked and laheledlplacarded,and are in all respects in proper condition for transport according to applicable international and national governmental regulations. <br /> Genera€orsr a Pr t ped N 0ft or C it i n tut V� 99"aawv) M nth D <br /> ❑ wia y Year <br /> a 15.International Shipments <br /> � Import to U.S. ❑Export from ll.5. Portal enirylexit: <br /> Transporter Signature Lfor exports only): Dale leaving U.S.: <br /> LU <br /> 18.Transporter Acknowledgment of Receipt of Materials <br /> r- Transporter 1 P i tedrTyped Name Signature Month Day Year <br /> a Transporter 2 PrfntedlTyped Name Signature Month bay Year <br /> sc <br /> 17,Discrepancy <br /> 17a.Discrepancy Indication Space ❑Quantify ❑Type ❑Residue ❑Partial Rejection <br /> ❑Full Rejection <br /> Manifest Reference Number. <br /> 171b.Alternate Facility(or Generator) U.S.EPA.ID Number <br /> U <br /> w Facitity's Phone: <br /> 17c-Signature of Alternate Facility(or Generator) Month Day Year <br /> C3 <br /> w <br /> w <br /> d <br /> 18.Designated Facility Owner or Operator.Certificafion of receipt of materials covered by the manifest except a d in Item 17a <br /> Printed+ yped Name natu aName nate thh <br /> 16"LC-0 5 11977(Rev.9109) DESIGNATED FACILITY YO GENERATOR <br />