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NON-HAZARDOUS 1.Generator 10 Number Pagalot 3.1imergencyliesponsePhone 4.wasteTradking Number <br /> WASTE MANIFEST 532 <br /> 217 <br /> 5,Generaloes Name and Mailing Address 7- Gervarstor's Site Address(it different than mailing address) <br /> 76 <br /> ai, AU L .— Z&i-"'r Q1 CbZD <br /> Generators Phone <br /> 6.1anspoder 1 Company Name U.S.EPA ID Number <br /> 7.Transporter 2 Company Nam U.S.EPA ID Number <br /> 8.D9MLataM44Ma,ndSiIq Address U.S.EPA ID Number <br /> �4 L <br /> Facility's Phone: <br /> 10,CmWners 11.Total 12,Unit <br /> go. gb.U.S.DOT Description Iinciuding Proper Shipping Nam) No. Type Quantity WtAkrl. <br /> w 1. • ..l tt.�i- <br /> 0 XC% C: .1 C <br /> 1 T— S 0 <br /> W <br /> o jrj F, <br /> 3. <br /> 4. <br /> 13.Special HandikV Instructions and Additional Intonation <br /> f <br /> 71CM�4-1 7 <br /> 14.GENERATOR'S CERIMPEATION:I certify the Materials described above on this menjigst are not subjed to federal regulations for reporting proper disposal of Hazardous Waste. <br /> Signature Month Day Year <br /> I 1 15.International Shipments El import to U.S. EIExport from U.S. Port of en'trylaxit: <br /> 9 Transporter Signature t'for e)wrts only): Date leaving U.S.: <br /> w 16jranspogtm Ackrvhedqemerg of Recelptol Materials 4 <br /> cc Transports'I Pdntegped Nam Signature Month Day Year <br /> 0 <br /> Z TransporterZPvIntecirryped Nam S"toreMonth Day Year <br /> 17.Discrepancy <br /> Partial Rejection Full Rejection <br /> 17a 01 my Indication Space El dummy El Type D Residue <br /> Manifest Reference NLvnber: <br /> 17b.Alternate Facility for Generator) U.S.EPA ID Number <br /> 17C.Signature Of Aftenale FacHily Clerrialm) mmu, ny Yam <br /> Z <br /> Designated Facility Owner or Operator:Certification of receipt of materials covered by the manifest except as noted in Item 17a <br /> yl <br /> year <br /> Pnroed/Typed Name Signature Month Day <br /> .4 <br /> 169-BLC-0 5 11977(Rev.9/09) TRANSPORTER#1 <br />