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NON-HAZARDOUS I '.Generator ID Number "toe 2.Page I of 3.Emergency Res 4.Waste Tracking Number <br /> ap,nse Phone <br /> #,N ;�- <br /> VT JIT Ral-QUII.-:101 IL.14 <br /> WASTE MANIFEST I <br /> 5.Gen Na Mail' Address ress General jjeAddress iff freng1thanmailing <br /> IM, . xw3r a" <br /> ,x t Tj.,1111, <br /> PTRV.11,41; -a.Vy <br /> 75 84�,wum-_-0-I,CA !�711-B <br /> Generator's Phone: <br /> 6.Transporter I Company Name U.S.EPA ID Number <br /> /.w,Ancm hV,,4--q;rd WIQ131 <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> 8.Des' ted Facility Name and Site dress U.S.EPA ID Number <br /> 64, by a Mor i J�n T.-M. <br /> I�41 V 1. 1�-Xh Stszrl <br /> Facility's Phone: R1313 bZ?-4S74VA6 <br /> 9.Waste Shipping Name and Description 10.Containers I 11.Total 12.Unit <br /> No. Type Quantity WI.Nol. <br /> Cr 1. <br /> 'Vfr" .s 41 U'41 <br /> OI <br /> a <br /> cc <br /> LU <br /> z2. <br /> w0 <br /> T3.3. <br /> 4. <br /> am <br /> 13.Special Handling Instructions and Additional Information <br /> f dv--,kf L.equk�P� it 3 fir <br /> .wvwov*ji1r, 21 <br /> 14.GENERATOR'SlOFFEROR'S CERTIFICATION:I hereby declare that the contents of this consignment are fully and accurately described above by the proper shipping name,and are classified,packaged, <br /> marked and labeled/placarded,and are in all respects in proper condition for transport according to applicable international and national governmental regulations. <br /> Generato?Wfferor:,s nte Signature Month Day Year <br /> �j 15.International Shipments ❑import to U.S. El Export from U.S. Port of entry/exit: <br /> Transporter Signature for exports only): Date leaving U.S.: <br /> cc 16.Transporter Acknowledgment of Receipt of Materials <br /> w <br /> ►i Transporter 1 Printedrryped Name Signature MonthDay Year <br /> 0 _ I/ / 1 <br /> ATA <br /> z Transporter 2 PrintedfTyped Name SignatureMonth Day Year <br /> C_ <br /> 17.rDiscrepancy <br /> Discrepancy <br /> 17a.Discrepancy Indication Space ❑Type ❑Res Partial Rejection ❑Full Rejection <br /> El Quantity I sid.e I <br /> Manifest Hefererwe Number: <br /> 17b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> Facility's Phone: <br /> w 17c.Signature of Alternate Facility(or Genem for) Month Day Year <br /> z <br /> (9 <br /> Co <br /> w <br /> 18.Designated Facility Owner or Operator.Certification of receipt of materia.;covered by the manifest except as noted in Item 17a <br /> PrintedfTyped Name Signature Month Day Ye,a', <br /> 169-BLC-0 5 11977(Rev..9/09) TRANSPORTER#1 <br />