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GENERATOR NON-HAZARDOUS <br />WASTE MANIFEST <br />I. Generator ID Number <br />C .1)075528575 <br />2. Page 1 of 3. Emergency Response Phone <br />1325-432-51U: <br />4. Waite Tricking Nunes.- <br />,, _ USW---U Ul ° 5 2 '.) 0 <br />5. Generators Name and Mailing Address Generators Site Address (If different than mailing address) <br />r.'7; OW C I-1 e Mr.:7..A.).. <br />¶10 1 LOVERfOGE ROAD <br />PaTseurto, CA 414553 <br />Generators Phone: 925-432-51CQ <br />S Transporter 1 Company Name U.S. EPA ID Number <br />Transporter 2 Company Name U.S. EPA ID Number <br />6 <br />I <br />Facia <br />Designated <br />....Nr_RNIORE, <br />Fatality ardlffeAddreas U.S. EPA ID Number jior mlcptL <br />CAOS41382732 <br />10540 ALT AMONT PASS 113A0 <br />CA9e5.81 <br />iris Phone: 925-4)5-73-rx; <br />10 Containers 11. Total 12. Unit 9 Waste Shipping Name and Description <br />No. Type Quantity VA.Nof. <br />sreNT c,AReori NON H.A2AROOVS,MON RCM-RATED .152052eCA <br />_ ..,. i.n 9-5.: 10 CA) 91) IRI_ Itit <br />P <br />13 Special Handling instruchons arid Additional Infornalhon <br />NEEOS CO SEW' TO US WASTE 24 HR EMER (P.?.!4MC Y CONTACT LARRY LUPRANO 925-024102 <br />CAI GOP; CARECf.1 COPP- STOCKTON, CA <br />446r(eil Dtfr- 1410 ) 3c)-72,-/ <br />14. GENERATOR'S/OFFERORS CERTIFICATION: thereby declare that the contents of this consignment are fully and accurately &molted above by the proper shipping some, and are classified, ckaged, <br />marked and labelecUplacarded, and are in all respects in proper catition for transport according to applicable international and national governmental reguladons. <br />Generators/Offerors Printed/Typed Name Signature I Month Dr Yeilt. <br />- I -‘, r 1.. r ) t /./ <br />-i <br />I- <br />3 <br />15. International Shipments 1.1 anportio U.S. . Export from U.S. of entry/exit' ' <br />rtte Transporter Signature (forMOdOns °MY)) leaving U.S. , TRANSPORTER 16. Transporter Acknowledgment of Recelat sil Materials <br />Transporter 1 Printed/Typed Name Signature e Month Day Veer <br />_. <br />I' ti- I el•''' <br />Transporter 2 Printed/Typed NaMe Signature Mona, ' Day Year <br />I -41- DESIGNATED FACILITY -N. 17. Discrepancy <br />17e. Discrepancy Indication Space . Quantity li Type NI Residue III Partial Rejection II Full Rejection ' <br />Manifest Reference Number: <br />175. Alternate Facility (or Generator) U.S. EPA ID Number <br />Facility's Phone <br />17c. Signature of Alternate Family (or Generator) Month Day Veer <br />II <br />18. Designated Facility Owner or Operator Certification of recent of materials covered by the manilest except as noted in tern 17a <br />Printed/Typed Name Signature Month Day Year <br />1 I I I <br />169-BLC-0 5 11977 (Rw. 9/09) <br /> <br />GENERATOR'S/SHIPPER'S INITIAL COPY <br />at-