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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 NOT REQUIRED 1 888-423-BOE 40040-48-019 <br /> 5.Generators Name and Mailing Address Generators Site Address(if different than mailing addressl <br /> 7-EW~ 7-EWW"Sbn No.8201M <br /> R.Q.Balt 711,Data TX 75221 4627 Do Vkrd Dr.,SbckhM CA 85247 <br /> Generator's Phone: wn) <br /> G.Transporter 1 Company a U.S.EPA ID Number <br /> NOT REQUIRED <br /> 7.Transporter 2 Compo Name U.S.EPA ID Number <br /> B.Designaled Facility Name and Site Address U.S.EPA 10 Number <br /> V&SID t'.OMMMAMi—po"M HIt I.WOM <br /> 3M PI OK0 HUb LAIN►,SufM.CA 94886 NOT REQUIRED <br /> Facility's Phone: W5)949-W1 <br /> 10.Containers 11.Total 12.Unit <br /> 9.waste Shipping Name and Description <br /> No. Type Quantity Wt..Nol. <br /> t. <br /> x <br /> a Noll FiRMCIWA VftZ a.Soil to" 001 D T 10 Y <br /> rr <br /> z 2. <br /> 3. <br /> 4. <br /> 1 a.Special Handling Instructions and Additional inlormation <br /> Sol:99-1 W% Pf*ft Na: PMF-204M <br /> Debrla:4-1% <br /> Vfter approprlab PPE when hsroAV or as FaguhW by#*TSM PM*d No:40M <br /> 14.GENERATOR'WOFFEROR'S CERTIFICATION:l 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 labeled/placarded,and are in all respects in proper condition for transport according to applicable international and nalional governmental regulations. <br /> GeneratorslPA" yon bew tX Mehr Month D �fYeeaarr <br /> Y L CrLJ <br /> j 15.Intemaliional Shipments <br /> ❑Import to U.S. ❑Export from U.S. Port of entrylexit: <br /> Transponer Signature Nr exports only): Date leaving U.S.: <br /> rC 16.Transporter Acknowledgment of Receipt of Materials Ot <br /> � <br /> anspoAer 1 Pri �)peri Name Signature Y Month Year <br /> 41 <br /> VVV <br /> Z Transporter 2 Prfntedfryped Name Signature Month Day Year <br /> a <br /> rr <br /> r <br /> 17.Discrepancy <br /> 17a.Discrepancy Indication Space <br /> ❑QUaniity ❑Type ❑Residue ❑Partial 13ejection ❑Full Rejection <br /> Manifest Reference Number, <br /> 17b.Alternate Facility for Generator) U.S.EPA Ip Number <br /> .a <br /> U <br /> r¢i Facility's Phone: <br /> 17c.Signature of Alternate Facility(or Generator) Month Day Year <br /> a <br /> 2 <br /> L17 <br /> w <br /> 18.Designated Facility Owner or Operator.Certification of receipt of materials covered by the manifest except as noted in Item 17a <br /> Printed(Typed Name Signature nth <br /> 3L.0-0 5 11977(Rev.9109) DESIGNATED FACILITY i0 GENERATOR <br />