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NON-HAZARDOUS 1 1.GaperalorrID Number j 2.Page 1 of 3.Emergency Response Phone 4.Waste tracking Number <br /> WASTE MANIFEST IL-17'Af". L� / 1 �j��1 1 BW-641-3940 J//J�' �`' ? /z/ <br /> 5,G lor's Na I' Add Generator's <br /> a „ r- Site Address(if d <br /> iH mrd than mailing address <br /> �� z iEj',r rv��_' - .) 1)7_4 <br /> �E5�9r� lsj 111J�y <br /> 6.Transporter 1 Company Name / U.S.EPA ID Number <br /> Environmental Logistics, Inc_ C A R 0 0 0 2 1 7 5 1 8 <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 /> Weznmt TSDF Inc. <br /> 1 BOW.Monte Avenue <br /> 131oomuvion CA 92316 <br /> Facili 's Phone: 909 421-2012 C A D 9 8 2 4 4 4 4 8 1 <br /> 9.Waste Shipping Name and Description 10.Containers 11.Total 12.Unit <br /> nn '� J� y r� f No. Type Quantity Wt.Nol. <br /> Ir 1S�I�L v 0 � <br /> ¢ <br /> W <br /> z 2. <br /> W <br /> 0 <br /> 3. <br /> 4- <br /> 13.Special Handling IV <br /> ons and Additional Information <br /> 1Jz}ili l X3L' 4)A1 <br /> 14.GENERATOR'SIOFFEROR'S CERTIFICATION:I hereby declare that the contents of this consignment are fully and accurately descnbed abpve 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 intemational knd national mental regulations. <br /> Generator's/Offeror's Printed/Typed Name Signature Month Day Year <br /> j 15.International Shipments <br /> 1,_ 1:1 Import to U.S. El Export from U.S. Pori of entrylexit <br /> Transporter SI nature for exports only): Date leaven U.S.: <br /> m 16.Transporter Acknowledgment of Receipt of Materials <br /> Lu <br /> Trans orter 1 'n <br /> ¢ p ped N��i Signal �� Month Day Year <br /> y 1'or/ <br /> �� � y I f <br /> z Transporter IP yped Name Signa Month Day Year <br /> a <br /> F <br /> 17.Discrepancy <br />� 17a.Discrepancy Indication Space <br /> ❑Quantity ❑Type ❑Residue ❑Partial Rejection ❑Full Rejection <br /> I <br /> Manifest Reference Number: <br /> 17b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> J_ <br /> V <br /> rai Facility's Phone: <br /> Lu 17c.Signature of Alternate Facility(or Generator) Month Day Year <br /> z <br /> (7 <br /> N <br /> W <br /> 18.Designated Facility Owner or Operator:Certification of receipt of materials covered by the manifest except as noted in Item 17a <br /> Printecnyped Name Signature Month Day Year <br /> 169-BLC-0 5 11977(Rev.9/09) DESIGNATED FACILITY TO GENERATOR <br />