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1 GENERATOR r NON-HAZARDOUS <br />WASTE MANIFEST <br />1 Generator ID Number 2. Page 1 of <br />I <br />3. Emergency Response Phone <br />61.4)-424 '..' i .. ' <br />4. Waste TrecIdng Number <br />i I 1 1 WM :4 ill ., 2 0 3 <br />1 tKiGeherapt'sSite.Addresa Rdiff grant u•an me.ing antress) 5 Gc-.!':•ator's Name and M.4)1ing Address '1 N <br />,.;..:11* . K,S Irn... VEY% Try Nou bemoan:. int / Iran ..;q11II <br />I 2 I L. Eledia:, RU Suite 130 MI Nairknd Street <br />Cxspet UT 8400 Stockton CA 95206 <br />Generator's Phone. 442 die.M. IHIS I <br />6. Transporter 1 Company Name U.S. EPA ID Number <br />ElivirunnWittal LOgLit'..- . lilt: CAPU301 <br />7 Transporter 2 Company Name US. EPA ID Number <br />8. Des ed FacritaarricSde Address U.S. EPA ID Number <br />100W. ?knit Avenue <br />ricernIngton CA snis <br />, A 0 9 3 ,:' .-. 4 <br />Far Is Phone `Le 421.'21112 <br />io Containers 11. Total 12 Unit <br />9. Waste Shipping Name and Description <br />No. Tye -Otlartbn wuvol. <br />t t•loit Han:clots Wash Solkt (absorbent, diesel) <br />00 I DM - P-_, C) P <br />Special Handling Instructions and Adcibonal intimation 1S) Absorbent iv/ Diesel - 20101901 WOO M920:) <br />(nts'1) <br />GENERATOR'S/OFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by the proper shipping name. and are classified. packaged, <br />marked and tabetedyiecanSed, and are in all respects in proper condition for transport according to applicable international and national governmental regulations. <br />Generatoes/Offeror's PnntediTyped Name Signature Month Day Year <br />C • I -- , I io 123 12 ci <br />..1 <br />- <br />75. International Shipments 11 IIII Export from U.S. Port of entry/exit Import to U.S. <br />Transporter Signature (for exports only)! Dale leaving U.S • <br />cc <br />o ti 0 2 <br />i <br />Transporter Acknowledgment of Receipt of Materials <br />g Transporter IiiitzliT Name Signature .../ Month Day Year <br />. <br />.., ..._ . ,' ---- • e_f_-: . <br />( .- r I ' ": ''VZ," I/ 0 I; 2 6 . ' _ <br />Transporter 2 Printed/Typed Name Signature - Month Day Year <br />I I I <br />1 Discrepancy <br />17a Discrepancy Indication Space. auantty IN Type . Residue <br />Manifest Reference Number <br />MI Partial Rejection . Fab Rejection <br />17b. Alternate Facility (or Generator) <br />u. Faokty's Phone: <br />p 17c. Signature of Alternate Faci..ty (or Generator) <br />et <br />U.S. EPA ID Number <br /> <br />Month Day Year <br />I I I <br />Desgnated Facoty Owner or Operato,. Certification of receipt of matenals covered by the manifest except as rioted In hem 17a <br />Ptintedl'yped Name Signature <br /> <br />Month Day Year <br />GENERATOR'S/SHIPPER'S INITIAL COPY 169-BLC-0 5 11977 (Rev. 9/09)