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Xs - <br />NON-HAZARDOUS I. Generator ID Number 2. Page 1 of 3. Emergency Response Phone 4. Waste Tracking Number <br /> .21nrag-mo2._ . ..,..,_ <br />ti. _—WASTE,MANIPES-T— <br />so <br />CC <br />, <br />c., <br />At <br />-,, <br />5 .Generalors Name.and Mall'ng Mdress Co. Generators Site Addrese (if cifferent than malrang address) U-nark on tnywontimito manalyx_nent Chevron 2063-97 cio Chwon F'roducts Con-fmny linfa‘te OeNk 666 Wevt Weber Ave. P.O. Box 6664 Storkien, CA 952(16 San P,orrion, CA 04583 (677) 8Elef-M.144 Generators Prole: <br />6. Transporter 1 Company Name U.S. EPA ID Nurnber <br />setsHiRE 1 CARD110183P13 <br />7. Transporter 2 Company Name U.S. EPA ID Number <br />I <br />8. Designated Facility Name and Site Address <br />Slonions Industry, Ino. <br />WOO S. F.loie Avfinue <br />Vernon, r.:A clo060 (an) 277-IMO° <br />FaciftWe Phone: <br />U.S. EPA ID Number <br />, <br />CAII0i3to3otioa <br />10. Containers 11. Total 12. Unit 9. Waste Shipping Name and Description No. Type Quantity WI.Nol. <br />,..... <br />' Non DOT 11,411.01ml IkUtedol (Mud, Non-tlazeTdous) 5 f3A,1 5(--,) e <br />.. <br />IS. Spedal Handling Instructions and Additional Information <br />SITE INVESTIGATION (WATERADRILL P;FS1:21669-1-.) <br />cm-TINOS) ER 0 : N/A • SITE 10: 20037 <br />Mimi 2A; CEMC 2002g7-Ptie 1,14 1 <br />WEAR LEVEL 0 PPE 8; 8PLA3H PROTE:CTION (IF APPLICABLE) PROFILE 0: <br />14.0ENERATOR'S/OFFEROR'S CERTIFICATION: thereby declare that the contents of this consignment are fully and accujately described above by the proper skipping name, and are classified, packaged, <br />marked and labeled/placarded, and are In all respects in proper condition for transport according to applicable Interne "onaliend national governmental regulations. <br />Generator'slOfferors Printed/Wed Name <br />SI on bz--51f of gdnorator Lart,, MoothArf of BE eh <br />Signature <br />...-' • ( ..„--- <br />Month <br />9 <br />Da <br />-3. <br />Year Year <br />I . <br />— <br />16. International ShIpments Import to U.S. 1=1 Export from Ili:— Port of entry/wit: <br />Transporter Signature (for exports only): Date leaving. U.S.: <br />_ 0 a en z <br />r... <br />18. Transporter Acknowiedgment of Receipt or Materials <br />Transporter 1 Printed/1-y* Name Signature Month Day Yea <br />_., ( A i 1 i nii h i 1 I la L)31 1 -- <br />- Transporter 1PrintediTyped flung . Signature. •-• Month Day Year <br />1 I I DESIGNATED FACILITY 17. Discrepancy <br />Quantity a 17a- Discrepancy indication Space . Type 111 Residua Partial Rejecton Fun Rejection <br />Manifest Reference Number. <br />Mernate Featly (or Generator) U.S. EPA ID Number <br />Facility's Phone: <br />Signature of Alternate Facility (or Generator) Month Day Year <br />18. Designated Nasty Owner or Operator. Certification of receipt of materials covered by the manifest except as noted In Item 17a <br />Printed/Typed Name Signature Month Day <br />1 <br />Year <br />— — -- - <br />169-BLC-0 8 10498 (Rev. 9/09) <br /> GENERATOR'S