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NON-HAZARDOUS 1.Generator ID Number 2.Page 1 of 3.Emergan y Response Phone 4.Waste Tracking Number <br /> WASTE MANIFEST N D T REQUIRED i 888_crl 40040-40-M <br /> 5.Gensratods Name and Mailing Address Generators Site Address(if different than mailing address) <br /> 7-E ver 7-Eft"n SWN No.9201M <br /> P.D.BOX 711.DOMS TX M221 46V Do Vlnd Dr.,Sfoclbrt.CA 9lktt17 <br /> Generator's Phone: <br /> 6.Transporter ❑ a N /j U.S.EPA ID Number <br /> {/fes NOT REQUIRED <br /> 7.Transporter 2 C pang!Jame U.S.EPA ID Number <br /> S.Designated Facility Name and Site Address U.S.EPA ID Number <br /> Mob Canirmcbm-Pobm Fpm Landffi <br /> 3675 Poftm Flb Lane,Suisun.CA 94686 N❑T REQUIRED <br /> Facililys Phone: <br /> (9626)949-9451 <br /> B.Waste Shipping Name and Description iii.Containers 11.Total 12.Unit <br /> No. Type Quantity 4Vl.Nol. <br /> 1. <br /> x <br /> Non Kmrdom Mzb,SoN(Sail) 001 D T 10 Y <br /> W <br /> 2 2, <br /> W <br /> C7 <br /> 3. <br /> 4. <br /> 13.Special Handling Instructions and Additional Information <br /> Soo:99-1w% PrIoNM No: PHLF 204M <br /> Debft 0-1% <br /> IAF er app imprff b RPE when ht niOng or as required by#*TWF Project No:40M <br /> 14.GENERATOR'SIOFFEROR'S CERTIFICATION:I hereby declare that the contents of this consignment are fully and accurately described above by the proper shipp!rtg name.and are classified,packaged. <br /> marked and labeledlplacarded,and are in al!respects in proper condition for transport according to applicable international and national governmental regulations. <br /> Generator'srOflerors PdnloTyped Name Signature 7,� <br /> Day Year <br /> PwN*ft CormW on b~olL3,narabr fT'pt? v�lOCvrial6 {� �ignat�e+�i) <br /> _j 15.International Shipments <br /> Import to U.s. Export ham U.S. Port of entry/exit: <br /> Transporter Signature for exports only): Date leaving U.S.: <br /> w 16.Transporter Acknowledgment of Receipt of Materials <br /> 9 Transporter t PrintoTyped Name -1 �Signature Month D d <br /> r <br /> ° v 1�') �,I I I LA gyri <br /> z Transporter 2 Printedr-yped Name Signature Month Day Year <br /> a <br /> rr <br /> ti <br /> 17.Discrepancy <br /> 17a.Discrepancy Indication Space <br /> ❑Ruantify El Type ❑Residue ❑Partial Rejection ❑Full Rejeclicn <br /> Manifest Reference Number: <br /> 17b.Affemate Facility(orGeneratorj U.S.EPA ID Number <br /> U <br /> w Facillty's Phone: <br /> w 17c.Signature of Alternate Facility for Ceneratorf Month Day Year <br /> d <br /> 2 <br /> cS <br /> rU <br /> W <br /> q <br /> 18.Designated Facility Owner or Operator.Certific,41fof receipt of materials covered by the manifest except as noted in Item 17a <br /> PrintedTyped Name Signatrt a <br /> 189-BLC-0 5 11977{Fier.9108} DESIGNATED FACILITY GENERATOR <br />