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I1 <br /> NON-HAZARDOUS 1.Generator ID Numbe( 12.Pip I of 3.Emergsncy Response Plans 4.1'lasto Tracking Number �`'�� )) �* <br /> WASTE MANIFEST i�iid filrlk9)!�t �/ 1 (;C�(, f;2<tL:v D � W(0044, <br /> 6.Generators Noma and Iderlrng Address Generators Site Address(11 ddleient than malting address) <br /> W 1Y9drCa flus C/o VAA 12wi'(;<U*y( ► ,'. <br /> OM c4qMwe ort",Mt wtmpw,I", Gftd$4n,CA IBMT <br /> OenaratotaPhone: 317 d1i4--041 <br /> 6.Transpolar 1 Company Name U.S.EPA ID Number <br /> 7.Transporter 2 Company Name , U.S.EPA ID Number <br /> 8.Ded9naled Pact y Name and Site Address U.S,EPA ID Number <br /> >±`iD*j N;Ovi&,il),Im. <br /> law W. 1'7t11 4. <br /> Factli 's Phone: F'Qil (}4fL ei i ?,•-tt; C�_4ra <br /> 9.Waste Shipping Name and Description 10.CordaNers 11.TOICI 12.Unit <br /> No. Type Quantity WINol. <br /> r3�r�axrtircte ; Wus!,UqUM( iw) / �tt •IM ! <br /> 1 ��R 141,X' 1. <br /> 2. <br /> Received <br /> via email <br /> a 03-11-15 <br /> CRA <br /> 4 Indianapolis, IN <br /> 13.Specht Handling Instructions and Additional Information IE hd 10S; i .tti. e- 2 .1 <br /> Slip. 12WO <br /> Wislgc Far ,Faa aq�Irr�.st19 Flxti?ttliQ;r�);�U1�?ds ca�� r u:�P.1rA l,•t�t'fe >�1� ��� <br /> rt x aisnn'n+. -A hxff 1vr os'. Fr s4er(800)42.4-M)C41w1t ou. <br /> 14,GENERATOR'SKIFFEROR'S CERTIFICATION:I hareby doctife llkAl the ardente of INs oorslDrmenl ere Icily apd accuialely descri d ecg,�b`1q Ura plopf ahlppllg ran,a,aid me OW,e.1,packagsd <br /> marked and labelediplacarded,and are In 90(aspects In pmpor Condition for transport according to applicable fno ai lemalional and natig Semmental regulations. <br /> Oeneratoes101fwr'6 Pdntedrryped Name Slgualute \, Month Day Year <br /> r 15.Inlemalionai Sidpments "Lr <br /> F ❑Impact to U.S. ❑Export from U.S. Pod of enhy/ezlt.=• <br /> 2 <br /> Transpodef Signature for er ns ora : Dale leaning U.S.: _ <br /> 16.Transporter Acknowiedgment of Receipt of Materials <br /> Transporter 1 Pdntedrrypod Name Sif)ADIWe , hlorth Day- Year <br /> <6 4/1AfLT JN <br /> t 'Z <br /> Transporter 2 Piintedrrypod Name (Signature f ` Month Day Year <br /> 17.Discrepancy -- — <br /> 17a.Discrepency Indicillon£pnca Elt�I <br /> Qdanlily ❑Type LJ Residua ❑PmllCl Re(ectiou Full Ra)ecuan <br /> htaiidesl Rofaren,;e number: <br /> ? 17b.Allemato Facility(or Generator) U.S.EPA ID tiomber <br /> Facility's Phare: <br /> 17o.Signature of Allemato Facility(or Generator) hionth Day Year <br /> IR.UcstJa.dtJfeclliiyO,��PfOfOf4t116:G)r'.OtzlonCllecaiplolmOlerirl•?cM@rJdb�8r911r..18ostiavfleJrrvadiihaml7n _ -_- -__ <br /> PrinledltypedNAme Slgnitura Month Day Year <br /> 169-BLC-0 5 11977(Rev.9109) TRANSPORTER Ni <br />