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II <br /> • <br /> NON-HAZARDOUS I.Generator ID Number 2.Page 1 of 3.Emergency Response Phone 4.Waste Tracking Number <br /> WASTE MANIFESTi1i <br /> .(,7' 1:; j.4 17 1 1 tl, 7 1 <br /> S.Generators Name and Ma AddressGeneralor's Site Address Of different than mailing address) <br /> A`X Jr 21,1 I <br /> K <br /> bl-57 MOD PADk'-AVt2"'Ur- <br /> Genera't'o5?sCP"hbne. C!". c"�21)�, <br /> (I.Transporterl CompainyNamV:I.- U.S.EPA ID Number <br /> 1.rr <br /> 7. rjfoc� <br /> Yra4m -GR 6B.EkIDNT-mb6ie <br /> 8.Designated Facility,Name and Site Address U.S.EPA ID Number <br /> POT RER0 HILLB LAAE)FIL! <br /> �X?M'FIDTREPCI <br /> Facil SUSUN 1,11x` art MSG <br /> We Phone: I— <br /> 1O.Gontainers; 11.Total 12.Unit <br /> 9.Waste Shipping Name and Description <br /> No Type Quantity WtJVol. <br /> 1 <br /> NOIN SCUD(80L0wfr11 <br /> 0 1 1 'e <br /> HYF)ROCAR-00111'03) <br /> .1 S7wi -1 <br /> z 2. 11 <br /> 3. <br /> 4. <br /> 13.Special Handling Instructions and Additional Information <br /> V CRI Q R.0 P R 1-A!-1 S [,�V,3 0 f 47i 1, IJ. C T-.ai I. E Q ux I i r I'o f3.#/4'n! t3 �u ).r Ti1c, E3 F1 <br /> t-a--xL;- <br /> 1rt <br /> C 0 Ti 8 IJ V aN T:G .Cc6w C C'N 3 V L,7,A,t;yol ,E r-r,C� 2 I!i Cl q�, b 71. sjA 5 b E Y LT S10 1 t el 1'6. i�'�'m'M I-Ecn c oa E3 OvA <br /> ALV'12,0K, t? w <br /> 14.GENERATOR'SIOFFEROR'S CERTIFICATION:I hereby declare that the contents of this oc�gnment fully and accurately described above by the proper shipping name,and am classified,packaged, <br /> Jar marked and latheledliplacanded,and are in all respects In proper condition for transport according to applicable international and reform!governmental regulations. <br /> Generate s/Offeroes PrIntecitryped Name Signature 1/1- <br /> Mpnth Day Year <br /> ?14-e e, 1. jy <br /> -1 15.international Shipments El import to U.S. Elp.rl from U.S. P d of entry/wit <br /> Transporter Signature for exports only): Ie�—Zrq leaving U.S.:. <br /> o: 11,TmnspofterAcknov4od,m8ntofllemiptofMatedals <br /> w <br /> Trans porterl PrintediTypedNlaim Da �ellr. <br /> 0 <br /> z Transporter 2 PrInted/Typed Name Signature Month Day Yea, <br /> 17.Discrepancy <br /> 17a.Discrepancy Indication Space E]Quantity EITYP. El Residue ❑Partial Rejection El Full Rejection <br /> Manifest Reference Number. <br /> 17b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> mg <br /> LL FacilflVs Phone: <br /> �&J <br /> 17c,Signature of Alternate Facility(or Generator) Month Day Year <br /> z <br /> 18.Designated Facility Owner or Operator Certification of receipt of materials covered by the manifest except as noted in Item 17a,., <br /> PdntecVTyped Name I Signature Month Dipr 1 Year <br /> 1G9-BLG-0 6 10498(Rev.9109) TRANSPORTER#2 <br />