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9 FO -4561 <br /> NON-HA7ARO0US ,Generator 11)Number 2.Page 1 of &Emergency Response Phone 4.Waste Tracking Number <br /> WASTE MANIFEST NOT REQUIRED 1 888-423-GOW —t 4004D48-029 <br /> S.Generator's Name and Mailing Address Generators Site Address(if different than mailing address) <br /> 7-Bran 7-EkWn SbM No 01201M <br /> P.O.Box 711,I)SIM TX 7=1 4W7 De Vinci Dr-Sbditn,CA 95M <br /> Generator's Phone <br /> fi.Transporter t Q4a9g74N1- J.S-EPA Ip Number <br /> �JJ� (/J NOT REQUIRED <br /> 7.Transporter ompany Name U.S.EPA ID Number <br /> 8.Designated Facility Name and Site Address U.S.EPA H7 Number <br /> V&"CwdwCw=-Potrero Hft UM M <br /> 3675 PONM Fift LOM,SWUM,CA 94M NOT REQUIRED <br /> Facili .s Phone: (925) 1 <br /> 9.Waste Shipping Name and Description 10-Containers 11.Total 12.Unit <br /> No. Type Quantity MNo!- <br /> 1. <br /> ° NOn FlWWCk ur VI M,SW{SDS 001 D T ' Y <br /> oac i <br /> w <br /> 2- <br /> c� <br /> 3. <br /> A. <br /> 11 Special Handling Instructions and Additional Information <br /> Sol:93-1w% PfoiM ND: PHU 204M <br /> Debft 0-1% <br /> VAw oppropftb PPE IIYim i1ef1l V or ata mqL*ed by ft TSW PMJ*d W.40M <br /> 14.GENERATOR'SIOFFEROR'S CERTIFICATION:l hereby declare that the contents of this consignment are fully and accurately described above by the proper shipping rrsme,and are classified,packaged, <br /> marked and labeledlplacarded,and are in all respects in proper condition for transport aocarding to applicable intemationat and rational governmental regulations. <br /> Generator srOffern s P�dn ped Name b~of� i n tpur f��f� Month Da Year <br /> .j 15.Internalional Shipments l 'J,t[/j <br /> Import to U.S. ❑Export from U.S- Port of aneyrexih <br /> 2 Transporter Signature(Vexlaorts on : Date leaving U.S-: <br /> U) 16.Transporter Acknowledgment of Receipt of Materials <br /> Tprr roe Name Signature rah Day ar <br /> , 17 <br /> a Transporter 2 PrinWEIrTyped Name Signature Month Day Year <br /> oc <br /> i•- <br /> '.7.Discrepancy <br /> 17a.Discrepancy Indication Space <br /> ❑Quantity 171 Type 1:1 Residue LJ Partial Rejection L1 Full Rejection <br /> Manifest Reference Number. <br /> 17b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> J <br /> U <br /> Facility's Phone: <br /> w 17c.Signature of Altemate Facility(or Generator) Month Day Year <br /> zUj <br /> l l l <br /> rn <br /> 18.Designated Facility Owner or Operator:Certification of re eipt of materials covered by the manifest except as noted in Item 17a <br /> Printedliyped Name Signai o th pj Year <br /> 169-BLC-0 5 11977(Rev.9109) DESIGNATED FACILITY TO GENERATOR <br />