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NON-HAZARDOUS 1. Generator ID Number <br />--='-----!:7,-,---'" -4,-.,.----Cir4M1-44261--Q---...4.-- <br />2. Par lot 3. Enterlencx R nse Phone <br />(11W3.-441-' aa°-- - ---------- <br />4. Waste Tracking Number <br />W AST E2 M ANIF EST ---,---i <br />51,ViVe4 tagiriatiadknomernontCo. <br />eeneratoes Site icss ce Tenn( than matting address) <br />ChOvioft ..C153-9,. <br />tlo Csevroa Pteduotfi Corivstfy Waz-to OP.4 606 Vtfetd ViiMint AVo P.(). Vox WWI <br />SHn Rartton, CA, 04503 (877) 3864044 SiOdttr..tB, CA 952116 <br />Generatoes Phone: <br />6. Transparter 1 Company Name U.S. EPA ID Number <br />DEISM RE 1 rAR000163ci I 3 <br />7. Transporter 2 Company Name U.S. EPA ID Number <br />8. Dealonated Facitity Name and Stie Address U.S. EPA ID Number <br />'3M)- Sato <br />12B28 MI ttl.)5 Atle, <br />Ark:lento, CA 92301 (800) 802-80(J1 <br />Facfrys Phone: <br />10. Containers 11. Total la Unit <br />9. Waste Shipping Name and Description No. Type 0Flantity Wt.Nol. <br />Ix <br />g, <br />d w <br />' Non DOT Regulated 11.rintecitl (73011 motsmingted with <br />etroleoctsoazacoa <br /> <br />ur prdu, nn hrit) )p <br />. <br />(l Il) <br />z <br />0.., <br />, <br />• <br />ef, <br />., <br />Special Handing Instructions and Additional Information <br />FATE:. INVIESTIOAlION (OFZiLi.. C.1 n-m(s) 13f-.:S1:216699 <br />ER(: N/A SITE 10: ZANY <br />To be bulked in EIES1 yard Part:Efl rxl.A., CE-MC 200:497/P6d 04'1 <br />WEAR LEVEL D PPE &S-...PL4 -31-1 PROT ECII ON (IF AFVLIC.AB.).,E) PROFILE 0: <br />GENERATOR'S1OFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above 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 international and national governmental regulations. <br />Generatoes/Offeroes Printed/Typed Name _ Signature ,,:„ <br />L.arry Maft-at of 1m en .7.,.1 behalf 1 of .9,enarator <br />mA-1 <br />,„..t..-‘,,,.._...,:e 1 °) <br />..w, ,ear., <br />Id -11 <br />-1 international Shipments LI from U.S. Port of entry/exh: Import to U.S. Expod <br />Transporter Signature (tor exports only): Date leaving U.S.: <br />cc Transporter Acknowledgment of Receipt of Materials ...-el <br />0 D. <br />I <br />Transporter 1 <br />L <br />Printedayped Name /-, _ _ ‘. ., Signature <br />Ci ( (1..,1 //7e0-1/ Y-1( t i <br />fOtth ..,,V2, lYty <br />-(:•:i -.'-4 t I l• --) <br />F <br />ransporter 2 Printed/Typed Narri Signature Month Day Year <br />1 1 I <br />Discrepancy <br />17a. Discrepancy Indication Space LI Quantity Type LI Residue Partial Rejection Full Rejection <br />Manifest Reference Number. <br />Ei <br />u_ <br />17b Alternate Facility (or Generator) <br />Facility's Phone: <br />U.S. EPA ID Number <br />ri <br />17c. Signature of Alternate Facility (or Genera Month Day Year <br />, <br />; <br />Lu <br />18 Designated Facility Owner or Operator. Certification of receipt of materials covered by the manifest except as noted In Item 178 <br />Printed/Typed Name Signature Month Day Year <br />1 I <br />GENERATOR'S/SHIPPER'S INITIAL COPY 169-BLC-0 6 10499 (Rev. 9/09)