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NON-HAZARDOUS 1 1.Generator ID Number 2,Page 1 of 3.Emergency Response Phone 4.Waste Tracking Number <br /> WASTE MANIFEST NOT REQUIRED 1 8135-4234M 40040-45-014 <br /> S.Generator's Name and Mailing Address Gsneralo(s Site Address(if different than mailing address) <br /> PA.Box 711,DBMS TX 75221 4627 N Vend Dr.,SkmkkK.CA 96207 <br /> Generator's Phone: 0 `) <br /> 6.Transporter 1 Co pany N 11.5.EPA ID Number <br /> NOT REQUfRED <br /> 7.Transporter 2 64pany Name U.S.EPA ID Number <br /> 8.Designated Facility Name and Site Address U.S.EPA If]Number <br /> VVM@b CordoClon-PCOM HOR LaFKM <br /> 36$Po11111Mra Hft LWA Ste,CA 94M NOT REQUIRED <br /> Facili 's Phone: � 01 <br /> S.Waste Shipping Name and Oescription 10.Containers 11.Total 12.Unit <br /> No. Type Ouan6ty WtNol. <br /> f, <br /> cc <br /> a Mores HaWftm W 11",Soil(SIM 001 DT 10 Y <br /> x <br /> w <br /> z 2. <br /> ua <br /> is <br /> 3. <br /> 4- <br /> 13.Special Handling lnstructions and Additional Information <br /> Sol:99-1w% PMM NO: PKK <br /> D&W.0-1% <br /> Vftw epproprf.r PPE when hwm2t or me required by On TSW Prood wo:40M <br /> 14.GENERATOR'SIOFFEROR'S CERTIFICATION:I hereby declare that the contents of this consignment are Cully and accurately desc0above by the proper shipping name,and are classrfied,packaged, <br /> marked and labeled/placarded,and are in all respects in proper condition for transport according to applicable international and rational governmental regutations. <br /> Generatederr ri t d Na n t� <br /> 4nWWm Mu ay Year <br /> IF 15.International Shlpmeras <br /> F Import to U.S. Export from U.S. Port of entry/exit: <br /> z Transporter Signature for exports one : Date leavin U.S.: <br /> ¢ I6.Transporter Acknowledgment of Receipt of Materials <br /> ui <br /> Trans p iter 1 Printed,Typed Name 5i�ture h90' Year <br /> Al b£V Pf14 1 <br /> N <br /> z Transporter 2 Printed/Typed Name Signature Month ay ear <br /> cc <br /> 17.Disorepan''y <br /> 17a.Discrepancy Indication Space ❑Type ❑Residue j j <br /> ❑QuanE' ❑Partial Rejection El Re eetian <br /> Manifest Reference Number: <br /> 17b.AQemata Facility(or Generatoo U.S.EPA ID Number <br /> J_ <br /> C.) <br /> Facility's Phone: <br /> w 17c.Signature of Aftemate Facility(or Generator) Month Day Year <br /> zz <br /> 2 <br /> w <br /> 18.Dasignated Facility Owner or Operator:Certifiaata of re 1p of materials covered by the manifest except as noted in Item a <br /> Printedrryped Name Signature JAlb y <br /> ass-8LC-O 5 11977(Rev.9109) DESJGNATED FACH I O GiV<ERe0F1 <br />