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NON HAZARDOUS 1.Generator ID Number 2.Page 1 of 3.Emergency Response Phone 4.Waste Tracking Number <br /> .' WASTE MANIFEST "` <br /> 5.Gepertor's Natrie�ndM�il Address Generator's Site Address('rf different than mailing address) <br /> p, isle o.,s lisi 1t;, i -- �;iir� t <br /> _ 1.y I� •sui� _�( iv"r'- x,1:3=��•,h�jt <br /> iJ L.�� 'v'.1aY'-ice -4Fa'SJ �'l�'l+s.. __ '�'rl•�� Lt.� <br /> Generator's Phone: <br /> 6.Transporter 1 Company_Name U.S.EPA ID Number <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> B.Deto'gg.y Facility Name and Site Address U.S.EPA ID Number - <br /> a '2 <br /> 3241 i_9 <br /> 77 <br /> Facil' s Phone: <br /> 10.Containers 11.Total 12.Unit <br /> 9.Waste Shipping Name and Description <br /> No. Type Quantity WtJVoI. <br /> 2. <br /> 15 r.X <br /> 3. <br /> a <br /> i <br /> 13. Special a' Handling Instructions io s_and Additional Information <br /> 14.GENERATOR'S/OFFEROR'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 /> r Generator's/Offeroes Printed/Typed Name ature Month Day l!Year <br /> 1! <br /> t J t5.International Shipments <br /> ❑Import to U.S. ❑Export from U.S. Port of entry/exit: <br /> ? <br /> Transporter Signature for exports only): Date leaving U.S.: <br /> o: 16.Tradsport cknowledgment of Receipt of Materials <br /> ,^ o Transpo ('rinte ped Nam" ��e Signature Mph Day r <br /> fL <br /> z ransporter 2 Printed/Typed Nam,e r6 Signature Month - Day Year <br /> -: cc <br /> 17.Discrepancy <br /> 17a.Discrepancy Indication Space <br /> ❑Quantity El Type 1:1 Residue ❑Partial Rejection ❑Full Rejection <br /> Manifest Reference Number: <br /> 17b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> J <br /> u4 Facility's Phone:' <br /> w 17c.Signature of Alternate Facility(or Generator) Month Day Year <br /> z <br /> Ch <br /> ..' w <br /> o <br /> 1 B.Designated Facility Owner or Operator:Certification of receipt of materials covered by the manifest except as noted in Item 17a <br /> Printed/Typed Name Signature Month Day Year <br /> 169-BLC-0 6 10498(Rev.9/09) DE£al{"NALTED FACILITY TO GENERATOF <br />