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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.Generator's Name and Mailing Address Generator's Site Address(it different than maiing'address) <br /> PIR i,.r. <br /> C),}('r,jilrt C." ioti,t,r, <br /> GeneratoPs Phone: <br /> 6.Transporter 1 Company Name <br /> U.S.EPA tQ Number <br /> EtIV'P"d$± it�st I0,T, - if#; <br /> 7,Transporter 2 Company Name U.S.EPA ID Number <br /> 8.Designated Facility Name and Sita Address U.S.EPA ID Number <br /> r I'',r;, 't "TF <br /> i,'1 i_�.vit <br /> FacBi 's Phone: ',, c;` r41. <br /> 2.0 9.Waste Shipping Name and Description <br /> 10.Containers 11.Total 12.Unit <br /> Na. Type Quantity WIJVol <br /> 1 <br /> IE <br /> 1 2r[c^, . <br /> r ¢ <br /> W <br /> z <br /> W 2 <br /> r 3. <br /> �..r 4. <br /> 13. Special Handling Instructions and Addie of Information <br /> low <br /> .1lr t r�`'t 1';�f'r S' i Sl 3e. ,.r• 'rA, If i;I; <br /> 14.GENERAMR'SIOFFEROR'S CERTIFICATION:I hereby declare that the contents of Ihfs consignment ate fully and accurately described above by the proper shipping name,rind are classified•packaged, <br /> marked and labeledlplacanded,and are in all respects in proper condition for transport according to applicable international and national governmental regulations. <br /> Generator'srOfferor'sPtNtediTypedName Si ture f t Month Day Year <br /> r /� tr�.rS s�i�'�'3+�`�JI)'I f` •�{ �` ,r� r J 4 {_ � _� }r j., ---- t ��• � ' /,`'t <br /> 15.International Shipments <br /> ❑Import to U.S. ❑Export tram U.S. Port of entrylexit: <br /> Transporter Signature for expons only): Date leaving U,S.:. <br /> r..r ¢ 16.Transporter Acknovrledgment of Receipt of Materials 1 <br /> Transpodei i P I1 drr d_Name Signalr Month Day Year <br /> L/ <br /> /yrs <br /> z Transporter 2 Pn#dfTyped Name Signature Month Day Year <br /> low <br /> 17 Discrepancy <br /> 17a.Discrepancy indication Space El Quantity ❑Type ❑Residue ❑partial Rejection ❑Full Rejection <br /> bw <br /> Manifest Reference Number. <br /> } 17b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> ter U <br /> LL Facility's Phone: <br /> zi 7c.Signature of Alternate Facility(or Generator) Month Day Year <br /> z <br /> IBM rn <br /> W <br /> 0 <br /> 18.Designated'Facility Owner or Operalor.Certification of recgipt of matedais covered by the manifest except as noted In Item ia <br /> PrintediTyped Name / (r Signature <br /> } �g , Monthr Day Yew <br /> 169-BLC-0 5 11977(Rev.9/09) fi TRANSPORTER 01 <br /> r <br />