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.4 GENERATOR 1.- NON-HAZARDOUS <br />WASTE MANIFEST <br />1. Generator ID Number <br />,A041.78628872 <br />2. Page 1 of 3. Emergency Response Phone <br />WS-02-5102 <br />4. West. Tracking Numbs <br />USW L1 U 4 7 2 6 <br />5 Generator's Name and Mailing Address Generator's Site Address it (Afferent than mailing address) <br />DOW C11EM1CAL <br />SOI Lovernorae ROAD <br />PITTS-EURO. , CA 9.4885 <br />Generator's Phone. 925-4:12-5102 <br />6 Transporter 1 Company Name U.S. EPA ID Number <br />7. Transporter 2 Company Name U.S. EPA ID Number <br />I <br />8. Designated Facility Name and Site Address U.S. EPA ID Number <br />AkI.TAMONT L.Ata0F1LL C 4 0901114:7/ !-..., <br />10840 ALT AMONT PASS ROAD <br />LIVERMORE, CA94551 <br />Facility's Phone: 228-4SF- 7300 1 <br />and <br />10. Containers 11. Total 12. Unit 9. Waste Shipping Name Description <br />No. Type Chian* NAM. <br />1 SPENT CARBON NON NAZARDOUSSION REGULATED 86231128CA <br />1 e--- 1--)---7 ) C-.) (7V / <br /> <br />,j,t11 <br />sEp a 9 eve <br />Special Handling Instructions and Additional Information <br />NEEDS CO SENT TO U9 WASTE 24 NR EMERSENL", CONTACT LARRY LurocArac 92E4132-5 i O'd Ti) <br />CALGON CARSON CORP- STOCKTON, CA <br />----2- oile/ fr..1..,9 VC") <br />GENERATOR'S/OFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately descresed 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 />Generators/Offerors Printed/Typed Name Signature /,,i - Month Day Year . , <br /> i ,- <br />....: ,• ., <br />i 1 ‘..-7 '1-4,..,V - 7 A., ' ei . V' li-0 <br />— <br />- International Shipments -. • - t. <br />II Import to U.S. III Export horn U.S. i Port of entry/eat <br />Transporter Signature (for exports only)i Date leaving U.S.: <br />1 16 Transporter Acknowledgment of ReinemholMaterials <br />Transporter 1 Printed/Typed Seine S nature Month Day Y <br />- ---... CI I -&-t I ? (.. <br />Transporter 2 Priniedrryped Name Signature i Month Day Year <br />1 i I <br />u. <br />0 <br />Discrepancy <br />17a Discrepancy indication Space • Quantity . Type . Residue . Partial Rejection IIIII Full Rejection . <br />Manifest Reference Number. <br />176. Alternate Facility (or Generator' U.S. EPA ID Number <br />Facility's Phone: <br />17c. Signature of Alternate Facility (or Generator) Month Day Year <br />Designated Facility Owner or Operator Certification of receipt of materials covered by the manifest except as noted in Item 175 <br />Peered/typed Narne Signature Month Day Year <br />159-BLC-0 5 11977 (R9v. 9/09) GENERATOR'S/SHIPPER'S INITIAL COPY