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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 N D T REQUIRED 1 8884 234EW 40040-4$-Q13 <br /> 5.Generator's Name and Mailing Address Generators Site Address(if different than mailing address) <br /> 7-E 7-EWMA Sloes No.830632 <br /> P.Q.Box 7111,Deb* TX 7=11 4627 Da Vied Dr.,31sinbon.CA 9=7 <br /> Generator's Phone: <br /> 6.TransportezM <br /> U.&EPA i6 Number <br /> NOT REQUIRED <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> 8.Designated Faciiily Name and Site Address U,S.EPA ID Number <br /> Mift Cannedlum-Patm His LwrtN <br /> 3M POMM Hip Lang,SuMW4 CA 94585 NOT REQUIRED <br /> Facil' s Phone: � ^81 <br /> 9.Waste Shipping Name and Description 10.Containers 11.Total 12.Unit <br /> No. Type Quantity WVVol. <br /> 1. <br /> cc <br /> a Non Hararfdom YIb.Said( 001 D T 10 Y <br /> w <br /> z 2, <br /> W <br /> cs <br /> 3. <br /> 4. <br /> 13.Special Handling Instructions and Additional Information <br /> so,94-IW% PrOM NO: PMF 2Q4M <br /> Mw appropiftb PPE whm I wx"or n mq by the TSDF P100d N0:400 <br /> 14.GENERATOR'S10FFEROR'S CERTIFICATfON:I hereby declare that the contents of[his consignment are fulPy and accurately described above by the proper shipping name.and are ctass+fled,packaged, <br /> marked and€abeledrplacarded,and are in all respects In proper condition for transport according to applicable intemalional and national governmental regulations. <br /> Generatael"liba'Awon b~of Gwwvmw ��� Month Year <br /> ,z1!,? <br /> 15.Intemational Shipments <br /> Import to U'S. Export from U.S. Port of entrylexit <br /> - <br /> Transporter Signature for exports an : Dale leaving U.S.: <br /> w <br /> 15.Transporter Acknowledgment of Receipt of Materials <br /> Transporter 1 P imedlryped Name ['r, S�ature Month Year <br /> CL <br /> omaA� <br /> aTransporter 2 Printed(ryped Name Signature Month ay Year <br /> 17.Discrepancy <br /> 17a.Discrepancy indication Space <br /> ❑Lluantity El Type Ll Residue ❑partial Refection ❑Full Refection <br /> Manifest Reference Number: <br /> 171.Alternate Facility(or Generator) U.S.EPA ID Number <br /> zi <br /> Facility's Phone: <br /> w 17c.Signature of Alternate Facility(or Generator) Month Day Year <br /> a <br /> z <br /> 0 <br /> N <br /> w <br /> O <br /> 1 S.Designated Facility Owner or Operator: m'ffcatia of r t of materials covered by the manifest except as noted 17a <br /> Prinled)Typed!Jame Signatu v Y <br /> 1•,69-BLC-Q 5 11977(Rev.91179) DESIGNATED FACILE GENERATOR <br />