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Please print or typo. (Form designed for use on elite (12-pitch) typewriter.) GENERATOR NON-HAZARDOUS <br />WASTE MANIFEST <br />1. Generator ID Number <br />N A <br />2. Page 1 of <br />1 <br />3. Emergency Response Phone <br />1-800-899-4872 <br />4. Waste Tracking Number <br />N H - 1 8 0 8 2 0 - 0/._ <br />Generator's Name and Mailing Address Generator's Site Address (if different than mailing address) <br />ALPINE HEUCOM-R SERVICES ALPINE HELICOPTER SERVICES <br />11001 WHWY 12 6660 MAYBECK RD <br />LODI CA 25242 1 STOCKTON, CA CA 95206 <br />Generator's Phone. 208 360-0530 1 <br />Transporter 1 Company Name U.S. EPA ID Number <br />NRC ENVIRONMENTAL SERVICES INC. I CAR 0 00 0 3 0 1 1 4 <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 />POMERO HILLS LANDFILL <br />3675 POTRERO HILLS LN <br />SUISUN CITY CA 94585 <br />Facility's Phone: 707 432-4627 I C A R 0 0 0 0 8 9 4 8 8 <br />ga. 9b. U.S. DOT Description (Including Proper Shipping Name, Hazard Class, ID Number, 10. Containers 11. Total 12. Unit <br />HM and Packing Group (if any)) No. Type Quantity Wt.Nol. <br />1.Non-regulited material (Soli) <br />0 0 1 cm 0 d- 0 Y <br />2 <br />3 <br />4, <br />13. S ecial Handling Instructions and Additional Information <br />JOB* 180820 <br />PROFILE# PEL-2 2— 656 <br />14. GENERATOR'S CERTIFICATION: I certify the materials described above on this manifest are not subject to federal regulations for reporting proper disposal of Hazardous Waste, <br />Generator's/08e eted/Typed Name e I Signature Month Day Year <br />, , 1-1eLc...o A' "rG g 2crt/' C tr I re,,,,i. <br />1/G-7, P 8 1 ;..)- 1 ID Da mediia V-19 , b -1 . .... <br />— <br />15. International Sh Orients <br />Import to U.S. 0 Export from U.S. Port of entry/exit: <br />j <br />Transporter signature (for exports only): Date leaving U.S.: <br />ujIX <br />it <br />0 <br />a . u) z <br />g <br />16. Transporter Acknowledgment of Receipt of Materials <br />Transporter 1 Printed/Typed Name <br />Zood i, <br />Signature Month Day Year <br />r t , c„, -r...7 1 Og I 2- 2 1 di,2-1 <br />T or 2 Printed/Typed Name Signature Month Day Year .,:# <br />j <br />I I I I I 4 DESIGNATED FACILITY -0- I 17. Discrepancy <br />Discrepancy Indication Space Quantity Type Residue Partial Rejection Full Rejection <br />Manifest Reference Number: <br />Alternate Facihly (ot Generator) U S EPA ID Number <br />Facility's Phone: I <br />170. Signature of Alternate Facility (or Generator) Month Day Year <br />I I <br />18. Designated Facility Owner or Operator: Certific ateriaIs covered by the manifest except as not in Ile a <br />Printed/typed Name Signature X ill <br />6-NI-IM-C-C-11 <br />1-DESIGNATED FACILITY TO DESTINATION