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NON-HAZARDOUS 1•Generator ID Number 3; 2:Page 1 of 3 Emergency flesponse Phone 4 Waste Tracking Number
<br /> i. r WASTE MANIFEST ur F P J"
<br /> 5.Generatoes Name and Mailing AddressGenerator's Site Address(fl different than mailing address), +'
<br /> tit TO-0 i `I``�'JT'P { �,#EUAW C at�,l t<',�hit J f
<br /> a 4 119rPW 6 # ::MMPI-i'CENA:N 1
<br /> A.STSH"ISI .1;AWE,ISIJIFRG-5100 `-A CJ3725
<br /> i���i�. Pfl��� €} id�?�•Tt��� .
<br /> Generator's Phone. srr .," .4ul .
<br /> 6.Transporter 1 Compar"ry Name ' . U.S.EPA ID.Number , -
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<br /> rf ,r--i"i'i,:11Znr.tr:t'14i '13t. f li"1' 'i S`t .11 n r1. J1 23. !4, n1 ,1:,'i
<br /> ._. 7.Transporter 2 Company Name w•.'" U.S.EPA ID Number
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<br /> l 8.Designated Facility Name and Site Addressr
<br /> ' -U'S EPA`ID Number
<br /> Facility's Phone:
<br /> - 10.'Containers. "'11 Totai' 12 Univ ; sty
<br /> t 9.Waste Shipping Name and Description r
<br /> e No; type aQUanhty 'Wt./Vol.
<br /> t.f�",tv.#-JAZr't '(.`�1L. A�a "1t t" `?t� PI. V4
<br /> I CIA 000"16 Y
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<br /> 13'Special Handling Instructions and Addilional Inlormation
<br /> i t#Eil siJ? R '@r J fiE' F',1s#47iAlc ' T# OCI T T�rI :.; °�:. T'A P'3 `' i J' ;'3?C j>3,, �i�+€41E"tl is hi Jt)�rT}{aE'�1.4 y;�s;�iC j
<br /> f r ,214,1 ITO%PrP e! X0014 i".w' e� .�J Ji:.�i .at a +�3i� +�J 1 �J�f�+t��' �R � r•V- -vi�+ N'9�t�+
<br /> f tl` I;C.f k.5015 :F8MY•ic'
<br /> 14.GENERATOR'SIOFFEROR'S CERTIFICATION:I hereby,de'ciare that the contents of this 6risignment are fully and accurately described above by the proper shtppfng name,and are d14011ed,packaged,
<br /> marked and labeled/placarded,and are in all respects in proper'condilfon for transpod as ording:to applicable internationatand`natfonal goYammental regulations,,
<br /> Gj/enerator's/Offjeypes_Pdnle&T Ied Name Fp /(( f j "r Signature )' # r�M+� o_nntth,'' Day Year
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<br /> 15.International Shipments , n$ '
<br /> D Import to U:S �. Export Trom tj S� Pdit of entrylexit ,
<br /> Trans oder Si nature 4for ex orfs only): r r _ Date IeaVl U.S;:,,
<br /> 4
<br /> cc 18.Transporter Acknowledgment li Receipt of Male its'.
<br /> Transporter 1 Printed/typed Name. Signature_- g tJl nth Day, Year #,
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<br /> ,/ r y N q t.a•""�7: r 'f", �.lrz.'''-1r! e�r p" y , ,",} "t,
<br /> QTransporter Printed/fyped Name b ' Signature, J < "� Month Day Year
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<br /> 17.Discrepancy x v
<br /> 17a.Discrepancy indication Space -I —t
<br /> L J Quantity 3ype t_l Residue Partial Rejection ❑Full Rejection
<br /> ;Mariffost Reference Number
<br /> 17b,Alternate Facility(of Generator)"' l.,• U S.EPA`ID Number a k
<br /> LL Facility's Phorie:
<br /> Lu 17c.Signature of Alternate Facility.(or Generator):.. r, MofiBtt Day'' Year !
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<br /> 16:Designated facility Owner or Operator Cerfificatlonfof recetpl of materials covered by the mapifest except as noted in lie''17ay'y_ s °
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<br /> Pdntedrryped Name-' + Signature °1i r Mo)jMliJ�) ^�DJeti'4(Ji�/ i7r ar j/1'
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<br /> 169-BLC-0 6 10498 Rev.9/09 j� 7FiAN&OFITEh*2.:
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