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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 N❑T REQUIRED 1 888-4234MW 40 8-M <br /> 5.Generators Name and Mailing Address Generator's Site Address(if different than mailing address) <br /> 7-EbVKR 74EkW 1 Bubb NO. <br /> P.O.Boge 711,Dares TX 75M 4627 Da YW Dr.,Sloci",CA 9lS W <br /> Generator's Phone: <br /> S.Transp�fer�Cglhp �n , ,y U.S.EPR ID Number <br /> (r'F■-.11yw/[//J <br /> NOT REQUIRED <br /> 7.Transporter 2 Company Name U.S.EPA ID Nurnber <br /> 8 Designated Facility Name and Site Address U.S.EPA ID Number <br /> -111111411119 CAr11NKNOM-P06Ifllro HM Latr= <br /> 3675 Potaro HM Lana,StftM,CA 946M NOT REQUIRED <br /> Facili 's Phone: (925)90-W1 <br /> R.Waste Shipping Name and Description 10.Containers 11,Total 12.Unit <br /> Na Type Quantity Wt./Vol. <br /> t. <br /> Ix <br /> R. NM Fiait Y1111101r,SON(Sop) 001 D T 10 Y <br /> LU <br /> rr <br /> 2. <br /> LLI <br /> 3. <br /> 4. <br /> 13-Special Handling Instructions and Additional Information <br /> fto:99-1w% PF9ft No: PW-20-05 <br /> wliar spprtoprrale PPI=whm ha K"or as ragt*W by ft TSDF Projed No:40M <br /> 14,GENERATOWWOFFERQRTS CERTIFICATION:I hereby dedare 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 rn proper condition tot transport according to applicable intemational and national governmental regulations. <br /> Generators! err Pri ped Na On I�8 of CAWMIV N n turx4OCOVMemrj � �� Month Day Year <br /> 15.international Shipments ❑Import to U-S- ❑Export from U.S. Port of enlry/OAA <br /> ? <br /> Transporter Signature for exports on : Date leaving U.S.: <br /> m16-Transporter Acknowledgment of Receipt of Materials <br /> Ix oe <br /> Transporter 3 PtintedlTyped Name Signature Mo { y r <br /> Q <br /> a <br /> y <br /> a Transporter 2 Printed/Typed Name Signature Month Day Year <br /> cc <br /> W <br /> 17.Discrepancy <br /> 17a.Discrepancy Indication Space <br /> ❑Quantity ❑Type ❑Residue ❑Paftii3l Rejection ❑Full Rejection <br /> Manilast Reference Number: <br /> F 17b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> ra <br /> t¢i Facility's Phone: <br /> e 17c.Signature of Alternate Facility(or Generator) Month Day Year <br /> a <br /> z <br /> 2 <br /> w <br /> Lu <br /> n <br /> 18-Designated Facility Owner or 0elDaLgiXeitfication of receipt of materials covered by the manifest except as noted in Item <br /> PrintediTyped Name Signaturen! Year <br /> w COL I — —/ I -1 YA <br /> 169-BLC-0 5 11977(Rev.9109) DESIGNATED FACII_ITYTQ GENERATOR <br />