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NON-HAZARDOUS 1 1,Generaior ID Number 2.Page 1 of 3.Emergency Response Phone 4.Waste Tracking Number <br /> WASTE MANIFEST NOT REQUIRED 1 888-423.6060 4004046-015 <br /> 5.Generators Name and Mailing Address Generators Site Address(it different than mailing address) <br /> 7-Ekrs*n 7-EbVM SbN NO. <br /> P.O.On 7111.laws TX 73M 4M7 Do Vkba DL.sem.CA 952D7 <br /> Generator's Phone: ) <br /> 6.TransporterOXI�ZV <br /> U.S.EPA ID Number <br /> NOT REQUIRED <br /> 7.Transporter 2 06mpArky Name U.S.EPA ID Number <br /> S.Designated Facility Name and Site Address U.S.EPA ID Number <br /> 111Inb SIM-Pokwo Fft L arAN <br /> 3676 P01WO HMS LW* SUWM.CA 81686 NOT REQUIRED <br /> Facil' 's Phone: ) <br /> 9.Waste Shipping Name and Description 10.Containers 11-Total 12.Un t <br /> No. Type Quantity WlNvl. <br /> 1. <br /> x <br /> Non 1 UWdW 5 initiate,SOW(SON) 001 D T 10 Y <br /> x <br /> w <br /> z 2, <br /> w <br /> id <br /> 3. <br /> 4, <br /> 13.Special Handling Instructions and Additional Information <br /> V".'919-10D% I fait No: PH.F•20,05 <br /> Debda:D^1% <br /> Vhw appilapdob PPE when If1wKMV of me reQltmd by ft TWW pfoled NQ:40 80 <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 labeledlplacarded,and are in all respects in proper condition for transport according to applicable inlemall onal and national govemmental regulations. <br /> Generator's" *bMwDn waff ofG"Maw mw 9"ll" O M Ih Da Year, <br /> J 15.International Shipments p Export from U-S. Port of entrylextt: {••'(�/J <br /> im port to U.S. <br /> Transporter SI nature&r exports only): Date Ieavin U.S.: <br /> cc 16.Transporter Acknowledgment of Raoeipl of Materials <br /> w <br /> Transporter T Printed`Typed Name Signature Month Year <br /> a —T ,%/ <br /> N <br /> Transporter2 Pnntkgyped Name Signalure Month Day Year <br /> 17-Discrepancy <br /> 17a.Discrepancy Indleation Space ❑Quantity ❑Type ❑Residue ❑Partial Rejection ❑Full Rejection <br /> Manifest Reference Number: <br /> 17h.Alternate Facility(or Generator) U-S,EPA ID Number <br /> J_ <br /> V <br /> Facility's Phone; <br /> w 17c.Signature of 4emate Facility(or Generator) Month Day Year <br /> d <br /> z <br /> cs <br /> fA <br /> W <br /> 18.Designated Fatality Owner or Oper r;Cer1i Hca eipt of materials covered by the manifest oxcVt as noted in ReNa <br /> Printed7yped Name 5 alure <br /> 169-BLC-0 5 11977(Rev.9109) DESIGNATED FACILI TO GENERATOR <br />