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�',•JC:-.7f ':_l.:.:.Ck, C)l,i. : ��ii:''.:+_ �15:i <br /> NONHAZARDOUS 1.Genera o iD Number 2.Page I of 3 Emergency Response Ptrone A.Waste Tracking Number <br /> WASTE MANIFEST 11A 5qtpql <br /> _ <br /> 5.Generator's Name and Mailing Address ► Generators Site Address fit different than mailing addressl <br /> Slt+til baa a�,1:,ntr�ct <br /> Generator's Phone <br /> 6.Transporter I Company Name US EPA ID Number <br /> 7 Transporter 2 Company Naim 1. <br /> U.S.EPA ID Number <br /> 8.Designated Facility Name and Silo Address U.S EPA ID Number <br /> K-11111c tl'.(rcl«r+ti:=. ittt <br /> u .t91t!1Zt+ilieslBt r�ti'1'. <br /> FaCrrT tine:tt�.ut?t?iti.i r :A <br /> 9.Waste Shipping Name and Description <br /> 10.Containers I I Total 12.Unit <br /> u No. Type Quantity WI,Nol. <br /> 1. <br /> acr ?+i,,rr-}1f��rurit,tns st+t7ctc. llytt!rl <br /> u W <br /> Lu 2" <br /> t7 <br /> v 3 <br /> d. <br /> u , <br /> 13. Special Handling Instructions and Additional Information <br /> fJatc •! fx <br /> Wdil( �'(killull: <br /> 14.GENERATOR'S CERTIFICATION:t cerlity,the materials described above on this manifest are not subject to federal regulation for reporting proper disposal of Hazardous Waste <br /> Generat s+011eror's Pdnied(fyped Name Signature Monlh Day Year <br /> u Rd ])T- FGR Q y 7-, I FOR kill( o&oe, g Cb <br /> 1 15,International Shipments <br /> ❑Import W U.S. ❑Export from U.S. Rad o1 emrylexit: <br /> Tran der S nature flor exports only): Date leaving U.S.: <br /> u <br /> 16.Transporter Acknowledgment of Receipt of M erials <br /> Transpoder I Primed/Typed Nares, Signature Month Da Year <br /> o ((, p, <br /> N <br /> a Transporter 2 Print edlT Name Sgnalure Month Day Year <br /> L� <br /> 17 Discrepancy, <br /> 17a,Discrepancy Indcetton Space <br /> ❑Quantity F1 Type ❑Residue ❑Partial Rejection ❑Full Rejecrmn <br /> u <br /> Manifest Reference Number: <br /> 17b,Alternate Facility(or Generator) U.S.EPA ID Number <br /> U <br /> ' <br /> Facility's Phone. <br /> LOU 17c.Signature of Alternate Facility(or Generator) Month Day Year <br /> z <br /> 0 <br /> u w <br /> O <br /> 18.Designated Faa!iry Owner or Operator.Certification of receipt of materials covered by the manifest except as noted in item 17a <br /> v PrintediTyped Name Signature Month Day Year <br /> 4 VSA. <br /> u <br /> DESIGNATED FAGILiTY TO GENEFIATt)ic � 7` 135 <br />