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11/12/2007 09:08 FAX 2093683234 GEORGE KISHIDA INC Q008 <br /> NON-HAZARDOUS 1.Generator ID Number 2 Page 1 of 3.Emergency Response Phone 4.Waste Tracking Number <br /> WASTE MANIFEST , rl<ii1 ict reg J <br /> i "iii ii ''..ifr`'-t44't <br /> 5.Generator's Name and Mailing Address Generator's Site Address(11Idfifwent than mailing address) <br /> ? <br /> 725 ACEfU-441 <br /> Generator's Phone: <br /> B.Transporter 1 Company afne y U.S,EPA ID Number <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> 8.Designated Facility Name and Site Address U.&EPA ID Number <br /> f4tr;i.jJlE� ,Ei,:?W':AL a�1iv'.I?"K)WI f_f C <br /> Facil 's Phone: <br /> tainers <br /> 9.waste Shipping Name and Description 10.Con11.Total 12 Unit <br /> No. Type Quantity Wt.Nol. <br /> 0 -k <br /> W - <br /> x.. 3. <br /> - - 4. <br /> aoa= <br /> 13. Special Handling Instructions and Additional Inliomation <br /> 1,1},3��`f_E:f3`h t• 1)6i1�IC:,ftil C111Y1i-� f .w • <br /> 14,f1HERATORIS CERTIFICATIft I oartr7y air:matedaW described above on ttds manifest are riot SUDJect t0 federal regulations for mporteig proper disposal of Hazardous Wasts. <br /> Generator'srOffemrs Printed/Typed Name 3lgnature _ Month Day Year <br /> � i�'I. ..of Shipinenfs Im � ... . - <br /> z poo b U.S. ❑Export tom JS,. Port of entry/exit <br /> Transporter Signature for exports oI Date ieavI U.S.: <br /> w 18.Transporter Acknowledgment of Receipt of marleriats <br /> W <br /> Transporter 1 Prinfad(fyped Name Slgltalure Mom Day Year <br /> z Transpodor 2 Priaed7N Sig omitDay Yew <br /> a <br /> M <br /> 17.Discrepancy nn <br /> 17a.Discrepancy Indication Space ❑Rs.tiy ❑Type ❑Residue ❑Partial Rejection CI Ful Rejection <br /> Manifest Reference Number: <br /> F 17b.Alternate Fac}Ifty(or Generator) U.S.EPA ID Number <br /> J <br /> U <br /> LL Facility's Phone: <br /> w 17c.Signature of Aliemate Facifity(or Generetor) Month Day Year <br /> w - <br /> 18.Designated Facility Owner or Operawr.Cerlilicalion of receipt of materials covered by the martfeat except as noted in Item 17a <br /> PdnledrTyped Name Signature Month Day Year <br /> 16"L"6 10497(Rev.8106) GENERATOR'S/SHIPPER'S INITIAL COPY <br />