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NON-HAZARDOUS 1 1•Generator 10 Number 2.Page 1 of 3.Emergeney Response Phone 4.Waste Tracking Number <br /> WASTE MANIFEST N Q T REQUIRED 1 888-42341CW 4004048-C18 <br /> 5,Generator's Name and Mailing Address Generator's Site Address(if different than mailing address) <br /> 7-ENWM 7-EMrMM SUM N4.92063 <br /> R.d-On 711,Dsifilr TX 7522i 4627 De Vhd DL,SbddM CA 96207 <br /> Generator's Phone: WM 828-MM <br /> b-Transporter 1 Cam U.S.EPA ID Number <br /> r-T NOT REQUIRED <br /> 7.Transporter 2 Company Name U.S.EPA Ila Number <br /> 8-Designated Facility Name and Site Address U.S.EPA ID Number <br /> 3675 F+otratD His LatMll,S<ti m.CA 94686 NOT REQUIRED <br /> FacilitVs Phone: (925) i <br /> 9.Waste Shipping Name and Description 1p.Containers 11,Total 12-Unit <br /> No, Type Quantity WI./Vol, <br /> 1, <br /> ar <br /> a Not!Huwdous YID,Sam(wo 001 D T 10 Y <br /> ix <br /> W <br /> w <br /> 2- <br /> cs <br /> 3- <br /> 4- <br /> 13.Special Handling Instructions and Additional Information <br /> S0IL99-1w% Pr*M No: PRY-20-105 <br /> DIIIIIIIII1bft0-1% <br /> WV&w■ppmp hit PPE when hondilg W n agliod by On TSDF PWf ed No:40860 <br /> 14.GEN ERATOR'SIOFFEROR'S CERTIFICATION:I hereby declare that the contents of this consignment aro fully and accurately described above by the proper shipping name,and are classified,packaged, <br /> marked and tabeled)placerded,and are in all respects in proper condition for transport according to applicable international and national governmental Mutations. <br /> Generator'sl err Pr t ed Na �b~O[ 0 n tu� �C�� � Mo9th {]ay Year <br /> -1 15.Intemational ShipmentsIm art to U.S- <br /> p Export from U.S. Port of entrylexib <br /> z Trans iter Signature for exports only): Date leaving U.S.: <br /> LU <br /> 16-Transporter Acknowledgment of Receipt of Materials <br /> ¢ Transporter 1 P`nrled typed Name Signature Manlh Day Year <br /> Q TrAsprte Pan ed y ed Rame Sig fur f9on1h Day Year <br /> F <br /> 17-Discrepancy <br /> 17a.Discrepancy Indication Space <br /> ❑Quantity ❑Type Ll Residue ❑Partial Rejection ❑Full Rejection <br /> Manifest Reference Number: <br /> >- 17b.Altemate Facility(or Generator) U.S.EPA ID Number <br /> J <br /> U <br /> I Facility's Phone: <br /> w 1%.Signature of Altemate Facility(or Generator) Month Day Year <br /> a <br /> a <br /> 0 <br /> fA <br /> w <br /> O <br /> 18.Designated Facility Owner or Operator:Certification of receipt of materials covered by the manifest except as n in Item 17a <br /> PrintedlTyped Name lerl <br /> =I =7� - <br /> 174 1 <br /> 169-BLC-0 5 11977(Rev.9109) DESIGNATED FACILi O GENERATOR <br />