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GENERATOR NON-HAZARDOUS <br />WASTE MANIFEST <br />I Generator ID Number <br />,-)t1767!3 <br />2 Page 1 of 3 Emergency Response Phone <br />Sa5-4.32-6102 <br />4. Waste Tracking Numbe <br />USW t 1 CI li 521'31 <br />Generator's Name and Mailing Address Generators Site Address (it different than mailing address) <br />low CH e kV:. Akl_ <br />901 1_ OVERIOGf ROAD <br />cITTS'RIJRD, CA 94195 <br /> <br />Generator's Phon 925.43;-51Me* <br />Transporter 1 Company Name us. EPA ID Number <br />7 Transporter 2 Company Name U S. EPA ID Number <br />Facirt <br />8, DemtegieNNtelitLAddress <br />10640 <br />U.S. EPA ID Number <br />;:. , 7i.).' • ",, -, ALTAMONT PASS ROAD <br />lt IFRMORE, CA94651 <br />., Phone: 925-4.3.5-rsal <br />9. Waste Shipping Name and Description 10. Containers 11. Total 12 One <br />No Type Ouentity Wt."Vol <br />PENT CARSON NOR HAZARDOUS/MON SKIM-ATM weaae2eC,,, <br />Ca- r It -175 - lo‘N lig 01 81 <br />Cr r., <br />2 <br />d0A 11 n ../ 62 <br />Special Handling Instructions and Additional Ink:neuron <br />:1 eea s Co >et4T TC US wxste 24 MR MEP DENG Y CONTACT LARRY LURRAMO W26-432-6102 1 r_ <br />'.: AL001. CARRON CORP- STOCVTON, Ci• <br />"kr/ i / --Per —1:t ti.1013(-)175.0,5- <br />GENERATORVOFFEROR'S CERTIFICATION: I hereby declare eat the contents of this consignment are fully and accurately described above by the proper shipping name, and are classified, packaged. <br />marked and labelectelacarded. and am in all respects in proper corration for transport according to appecable international and national governmental regulations. <br />Generator's Offeror's Printed:Typed Name Signature Month Day Year <br />- <br />-.I <br />— <br />I 15 International Shipments Import to U.S III boon from U S Port of entry <br />Transporter Signature for exports only': Dale leawng U.S.' TRANSPORTER 16. Transporter Acknowledgment of Receipt, ofyaterials <br />Transporter 1 PrinteceTyped Name ,-,,. ... Srature Month Day Year <br />I <br />Transporter 2 PrinteiTyped Name Signature Month Day Year DESIGNATED FACILITY --10- 17 Discrepancy <br />17a. DsCrepancy Indication Space . Quantity <br />. Type El Revtlue . Partial Rejection . Full Rejection ' <br />Manifest Reference Number <br />17b Alternate Facility (or Generator) U.S. EPA ID Number a <br />Facility's Phone <br />17c Signature of Alternate Facility (or Generator) Month Day Year <br />18. Designated Facility Owner or Operator: Certification of receipt at materials covered by the manifest except as noted in Hem 17a <br />Printed/Typed Name Signature Month Day Yee <br />I <br />169-BLC-0 5 11977 (Rev. 9/09) <br /> <br />GENERATOR'S/SHIPPER'S INMAL COPY