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NON-HAZARDOUS 1.Generator ID Number 2,Page 1 of 3.Emergency Response Phone 4,Waste Track]ng Number <br /> WASTE MANIFEST NOT REQUIRED 1 8854234KW 4004D48-028 <br /> 5.Generator's Name and Mailing Address Generators Site Address{if different than mailing address} <br /> 7-EhrAM 7-Ekr~Sbn No. <br /> R.D.Bou 711,Dema TX 75M 4W Da Vbd Dr.,Sbcifbn,CA 9&W <br /> Generators Phone: w� <br /> 6.Transporter 1 orn ne .�} 641M <br /> U.S.EPA 10 Number <br /> J►S/.J/ NOT REQUIRED <br /> 7,Transporter 2 Company Name U.S.EPA ID Number <br /> 8,Designated Facility Name and Site Address U.S.EPA ID Number <br /> tea`Conneefto-PaOM0 Hlb LNUM <br /> 3675 Potrero Hft Lana,SUMLM,CA 94585 N O T R E Q U I R E D <br /> Facil' 's Phone: W6049-Mil <br /> 9.Waste Shipping Name and Description 10.Containers 11.Total 12.Unit <br /> No. Type Quantity WuVoI. <br /> Ir <br /> 1. <br /> Non 1-12=010ta Yl a de,Sold(Sod 001 D T 10 Y <br /> cc <br /> w <br /> 2 <br /> w <br /> 3. <br /> 4, <br /> 13.Special Handling lnslruclions and Additional Information <br /> SQr 99-100% Pnoft No: PHLF 20' 1 <br /> Dabft 0-1% <br /> mar appopriiiift PPE viAwn hmnO f8 or as lageiTgd by Om TSDF Pwod No:40= <br /> 14.GENERATOR'S/OFFEROR'S CERTiFICATtON:l hereby declare that the contents of ft consignment are fully arO accurately described above by the praper shipping name.and are classified,packaged, <br /> marked and tabetedlplacarded.and are in all respects in proper condition for transport according to applicable international and national governmental regulations. <br /> Generator s101falo Pr nted+,T(ed Name Signature f��� 2 €}�y Yea <br /> �IMF�.9fp lllf�On 8a11a8 0f K`7MM1��1�1' �P*'�+ yLi'L�+l �1/ "`,,'(((' ,,I�J�JJ <br /> ri 15.international Shipments ❑impartto i1.S. ❑Export from U.S. Port of enlrylexil: <br /> Transporter Signature for exports only): Date leaving U.S.: �1 <br /> cr 16.Transporter Acknowledgment of Receipt of Materials <br /> LU <br /> Transporter 1 f�dnt Name Si�atu e Mon Day Y <br /> ve r <br /> N � tir(J <br /> a Transporter 2 PnntedrTyped Name Signa Month Day Year <br /> 17.Discrepancy <br /> 17a.Discrepancy Indication Space ❑Quantity Type Residue Partial Rejection Full Rejection <br /> Manifest Reference Number: <br /> 17b.Altemate Facility{or Generalory U.S.EPA ID Number <br /> ..r <br /> U <br /> Fadllty's Phone: <br /> W 17c.Signature of Altemate Facility{or Generatory Month Day Year <br /> a <br /> z <br /> w <br /> a <br /> 18.Designated Facility Owner or Operator;Ceaffi5bn of receipt of materials covered by The manifest exc-pt as noted in Item a <br /> Printedffyped Name Signature Mp !h Y <br /> -01�A I /I 169-BLC-0 5 11977(Rev.9109) DESIGNATED FACILITY O GENERATOR <br />