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NON•HAIARDOUS 1•Generator p Number 2.Page t of 3.Emargency Response Phone 4, site Tracking Number <br /> WASTE MANIFEST 1 f�r,(1;i n':,!'• a.;r:O :�:}i ;t!.)•I ti i <br /> 6.fterator's Name and Mafgng Address Generator's Site Address Ill different than mailing address) I <br /> isiqvI,Cit1. It`•iilif;IYrifA�l %}Frt'4 Ye-f;tr 1) �` ti<'"!V:it i.t'`•,%I <br /> 'f <br /> ;�,L3,�'t�.;Q00a) rr',fC3: (''ft;t:'ti13ii9rft r �t1. , <br /> i1 t'f""A '..:'� s3r};i13.;' � �l'CiF�I?iTy t..d4 F'f'tr"1 i <br /> Oene �O�a Ij(wnes' (l'•i f'1 r1:tCu•i.?fildoy <br /> 6.Transporter I Company Name U.S.EPA ID Number <br /> I <br /> 7.T porter GoTparri Name U.S.EPA ID Number <br /> 8.Designated Facility Name and Site Address US.EPA ID Number t <br /> Facility's Phone: <br /> 9.Waste Shipping Name and Description 10.Confalnars <br /> 11.Trial 12 unit <br /> No. Type Ouentily WINol. <br /> t'{=.I:fi 1){J.1.I bs;t(f<'t`+'Tei((v)E i 4i)•7j (t;fiO .••:1rk'.3y11ioM:t=1'#with <br /> I1`Y(C^iEs lffl prodf.(<iS, t l;ll i2. <br /> 17 <br /> 4• I <br /> 13.Special Handing Instructions and Addllional Intormallon <br /> .f.r..• l(IN-.;•—I GAIi(AN) (f:;)i►l.a... t.i.+I fir'o-i <br /> I_;UiijiNE:;::,,3 <br /> yf7�1, fc'// r}'1 rT(;. ,r �l%I�{'`� � /��•.7,5�'�/../ YC1 i7+� r'-1.(iir'�?i{)I'?t-;t=`:ii V,. J <br /> ;•it,N I'iF r:Wr'(.i;'.',�(?i <br /> 14.GENERATOR'S/O FFEROR'S CERTIFICATION:I hereby declare that the contents of No consignment are fully and aocuralely described above by'the proper shipping name,and are classified,packaged, <br /> marked and IabeleWplacerded,and are in all respects In proper condition for Ifensporl aoeordkV to applicable International Vd nflioned governmental regulation& <br /> Genaratore/Offerces Printed/Typed Name Signature j ; <br /> ri r.-jr ne %i. tb D Yearn <br /> 16.International Shipments <br /> ❑Import b U.S. ❑Export from U.S. Port of entry/exi: <br /> Transporter Signature(for exports onlyl., Date leaft U.S.: <br /> o� 16.Transporter Admwledgmerd of Receipt of Materials f•} <br /> Tffan odl'ypeams <br /> er 1 PrlMed/ d � <br /> G { f J ,1 1 Slgnawre ,� 2th Day YeatTrapspoder Printed/Typed Name Signature ' Day Yea <br /> 7.Discrepancy t <br /> ! f <br /> 17a.Discrepancy Indication Space <br /> quantity E]Type Residue ❑Partial Rejection ❑Fug Refection <br /> Manf(est Reference Number. <br /> 17b.Alternate Faciliy(or Generalor) U.S.EPA ID Number <br /> ua- Faciiys Phone: <br /> g 17c.Signature of Alternate Faciiy(or Qsnarator) Month Day Year <br /> !�- 1 <br /> o fi <br /> 18. <br /> sig q artily Owner or Operator C ertttkstbn of receipt of materials covered by IN manifest except as noted In Item 17a + <br /> Prtrded/Typed'Namb, , <br /> Signature Month Day Year �( <br /> 169-BLG0 6 104913(Rev.9/09) TRA)JSPORTEH 42 <br />