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NON-HAZARDOUS 11,Generator ID Number 2.Page 1 of 3.Em§rgemy Response Phone 4,Waste Tracking Number <br /> WASTE MANIFEST I NOT REQUIRED i 81984234KW + 415-M7 <br /> 5.Generators Name and Mailing Address Generators Site Address(i€different than mailing address) <br /> 7-EWM 7-EM'M SWIV No.92= <br /> P.O.On 711,Drinan TX 7r',5M 4627 Dna Vk1d Dr.,S6Xkbn,CA 9=7 <br /> Generator's Phone: )828435M <br /> 6.Transpoaer,4 Comp Name w U.S.EPA 10 Number <br /> J/ I C NOT REQUIRED <br /> 7.Transpoder2 Company Name U.S.EPA 10 Number <br /> 8.Designated Facility Name and Site Address U.S.EPA 10 Number <br /> Mde GO11E1eMflfit-PWOM Hb L111111CM <br /> 3675 Potralro HM Lana,SUMM.CA+94585 NOT REQUIRED <br /> Facili 's Phone: <br /> 9.Waste Shipping Name and Description 10.Containers 11.'otal 12.Unit <br /> No, Type Quantity Wt.Nol. <br /> 1 - <br /> Non Haza1WW Yll da.S (&4 001 D T 115 Y <br /> w <br /> 2. <br /> cs <br /> 3. <br /> 4. <br /> 13.Special Handling Instructions and Additional Information <br /> SA 99'IW% Pmft No: PHLF 5 <br /> Dabft 0-1% <br /> IAlaar appl0pdoM PPE wIm I1aroMM Or Oa flegliad by ft TSDF ProOd No:40M <br /> 14.GEN ERATORTSfOFFEROR'S 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 Iabeledlplacarded,and are in all respects in proper condition for transport according to applicable intemational and naf onaf governmental regula5ons. <br /> Genarafor'slOPfer knt g=an am i natq ure � Mont Oay Year <br /> 15.intemational Shipments11 <br /> Import to U.S. Export from U.S. Port of entry/exit: <br /> z Tran rter S nature for exports only): Date reavin U.S.; <br /> rLI¢ 16.Transporter Acknowledgment of Receipt of Materials <br /> Tran art r t Printedliyped N e Sig aatu Mont Oa Yea <br /> N G� r <br /> ¢ Transporter 2 flrintedl7yped Name Sivam Month Day Year <br /> F" <br /> 17_Discrepancy <br /> 17a,Discrepancy Indication Space ❑Qatity Ll Type Rside Partial Rejection Full Rejection <br /> Manifest Reference Number. <br /> 17b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> J <br /> U <br /> cal Fadlity's Phone: <br /> w 17c.Signature of Alta male Facility(or Generator) Month Day Year <br /> a <br /> a <br /> c� <br /> w <br /> w <br /> 0 <br /> 18,Designated Facility Owner or Operator:Certification of receipt of materals covered by the manifest except as noted in item 17a <br /> Printed(ryped Name Signature i Y <br /> 1 B9-BLC-Q 5 11977(Rev.9109) DESIGNATED FACILITY TO GENERATOR <br />