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L11 L - Llg)qS)t6C� <br /> NONHAZARDOUS T.Generator lD Number E.Page 1 of 3.Emergency Rasponse one Q.Waste Tracking Number <br /> WASTE MANIFEST N Q T REQUIRED 1 888-47343= 4OD40 4&fl23 <br /> S.Generatoks Name and Mailing Address Generator's Site Address(if different than mailing address) <br /> 7-EbW 7-EW4M SbM No. <br /> P.M Oox 711,Dabs TX 752.'t1 4627 On Vlnd Dr..Sbci&M.CA 9007 <br /> Generator's Phone: (972)82$ <br /> 6.Transporter 1an U.S.EPA ID Numbe: <br /> NOT REQUIRED <br /> 7.Transporter 2 corfiparrvl4ame I U.S.EPA ID Number <br /> 8.Designated Facility Name and Site Address U.S.EPA ID Number <br /> ft CACWdi-Po"MH Mf:Lam <br /> 367511120a�pl4% i L ,St11u1,CA 94586 NOT REQUIRE D <br /> Fwli PhMI <br /> 's <br /> e: �)94--W1 <br /> R.Waste Shipping Name and Description 1a.Contalnefs 11.Total 12.Unit <br /> No, Type Quantity Wi.No1. <br /> 1. <br /> Non Ftazalr&W lAAM M,Sold(6010 001 DT 10 Y <br /> w <br /> 2. <br /> [d <br /> 3. <br /> 4- <br /> 13-Special Handling instructions and Additional Information <br /> W:99-10DX Pwft No: PF Y-20896 <br /> Dlablift 0-1% <br /> fter appimigideb PPE whm hwKM g of me FequkW by'wa TSM Project No:40260 <br /> 14.GI NERATORVOFFEROR'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 labeled/placarded,and are in all respects in proper condition for transport according to applicable intemalional and national governmental regulations. <br /> Generators! eras Prped Nar an br0f� i n lu r�r � Month Day Year <br /> F 15.Internet cite]Shipments ❑Impod to U.S. ❑Export from U.S. Pan of entrylexit: <br /> 2 Transporter Signature for ex ods only): Date Jeavirp U.S.r <br /> w 16.Transporter Acknowledgment of Receipt of Materials <br /> F Transporter t Printedffyped Name Siglature I MonthDa Year <br /> cc <br /> i —,-r A A <br /> fA <br /> a Transporter 2 PriMed.(TY eW Name Signature Month Day Year <br /> 2- <br /> 17.Discrepancy II <br /> 17A.Discrepancy Indication Space ❑Quantity ❑Type l_��J Residue ❑Partial Rejeotion ❑Full Rejection <br /> Manifest Reference Number: <br /> r 176.Alternate Facility(or Generator) U.S.EPA ID Number <br /> ..a <br /> U <br /> LL Facility's Phone: <br /> 17c.Signature of Altemate Facility(or Generator) Month Day Year <br /> a <br /> z <br /> c� <br /> UtIJ <br /> f] <br /> 18.Designated Facility Owner or Operator:Certifica ❑of reoei of matedafs covered by the manifest excV as noted i em 17 <br /> Printedfryped Name Si lura th Day <br /> �j I <br /> 169-BLC-05 11977(Fier.Mg) DESIGNATED FACILI TOG E A <br />