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NON-HAZARDOUS 1. Generator ID Number of t,
<br />WASTE MANIFEST
<br />5. Generator's
<br />1,-ACti):.• i' tilk:i 1:24
<br />2. Page 1
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<br />' 3. Emergency Response Phone
<br />t177-454,84,65
<br />4, Waste Tracking Number
<br />,22,20125)A01)
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<br />Name and Mailing Address Generator's Site Address (if different than niailingaddress) Mic., 424' siTzottfoitatoltli.2.1 tgote,,,, Do, imey) 14- WI*. itzaloolo p:,.
<br />V.16frkt6qt c.A. 012tVi• . . ' Gen eralOr's Phone: Alma; ,..44 mil I - 6.
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<br />TrabSperter 1 Company Name i r U.S. EPA ID Number
<br />rfPralf FiVri*ARTiiir*O1 re'll.il: i CA44,11 00VilMi 7. TransPerter 2 Company Herne U.S. EPA ID Number
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<br />8. Designated Facility Name and She Address U.S. EPA ID Number
<br />NIAMIK
<br />1 •Pti•••C A•iftpoi '.'":.,r;
<br />,t40 "41.1u, CA, 0-14) 4
<br />Facility's Phener fi4t1-751.16V I NIA _
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<br />9. Waste Shipping Name and Description 10. Containers If . Total 12. Unit
<br />No. Type Quantity VAAror.
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<br />13. Special
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<br />Handling Inshentlont and MditiOnal Information
<br />St'utAkt t:' 0.. 17 .._, ‘‘. .1.,t,t..i
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<br />14..GENSRATOR'S/O1FEROWS CERTIFICATION: I hereby declare that the contents of this consignment are fully and accleately described above by the proper shipping name, and are classified, packaged,
<br />marked and labeted(plicarded, and are In all *acts in Proper condition fel [rancor:fa according to applicable International arid national govemniental regulations. ..:4;•, - 611 ;A
<br />Generators/Crem(s PrIntettrTyped Mune Signature , ,, Month Day Year '
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<br />, 11 4-.' ^ 4.•.°4
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<br />.4 IS. Inlematicinal ShipmentsID Import to U.S. Export from U.S, Port of entrylexh •: gori v.,. SPORTER 110 Transporter Signature (far exports only): Dale teavir,g U.S.:
<br />Transporter AcknoWledgment of Receipt of Materials at
<br />r.- Transporter I Printed/Typed Name Signature Month pay Year I .... • r."-"c• ,...-- ---i!...,..,... .* ? ' ,.• . .,
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<br />- r. , = _ Transporter 2 Printed/Typed Name Signature Month Day Year
<br />I I 1 Discrepancy
<br />17e. Discrepancy Indication Space
<br />Quantity Type Residue ID Partial Reiection 0Fuil Relectn
<br />Manifest fie!erance Number.
<br />"....4 DESIGNATED FACILITY 17b. Alternate Facility (or Generator) U.S. EPA ID Number
<br />Facility's Phone: I
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<br />170. Signature of Alternate Faerty (or Generator) Month Day Year
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<br />18. Designated Facility Owner or Operator: Certification at receipt of materials covered by the manifest except as noted in hem. 17a
<br />, Printed/Typed Name ' — 7 •,. Signature ,.'t• Month Dey Year ..
<br />I_.• t V 17 1/ '.,' .....' . ' e i j
<br />169-SLC-0 6 10498 (Rev. 9(09) TRANSPORTER #1
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