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' [ION-HAZARDOUS 1 Generator ID Number P Page 1 of 3 Emergency Response Phone 4.Waste Tracking Number <br /> WASTE MANIFEST <br /> 5 Generator's Name.and Mailing Address _ I _l". ..L'_Ls Generator's Site Address(if different than mailing address) <br /> st f i.� ' -��{Lrt fair s {� )Jtt t� '•.L A "' ) i <br /> r <br /> 3,21 <br /> Generator's Phone. c-': r )• <br /> 6.Transporter 1 Company Name',._'. U.S.EPA ID Number <br /> .,t .. .. `_.. '',( H, ft .`.' i_ <br /> ' 7.Transporter 2 Company Name U.S.EPA ID Number ;t <br /> s <br /> ' e Designated Facility Name and Site Address. - U.S.EPA ID Number <br /> 1 e�' � .r i'fI �✓c 4? <br /> 10.Containers 11.Total 12.Unit <br /> 9.Waste Shipping Name and Description •1 <br /> No. Type Quantity Wt.Nol. <br /> 1 ''i:P t .r { r tl r '.. _`t, <br /> w <br /> 2. <br /> W k <br /> 1 J <br /> Y <br /> r 3. <br /> J <br /> 4. <br /> 13 Special Handling Instructions and Additional Information <br /> u y n r n •er^+., r r 'r-i Y': r 1/'� ?, ?d r v,;.r, :.,`< i <br /> i _:- l_�.rL_.r..�'L _'e{Tt_e7[�hlr 'L1FlC.FS r:.7..rr' .,._1:n,4.., ,9�:• ..3 : : J t 1 _ : <br /> �i .L., i,!'i 'atS 'tC 1:'t: ..i :»;�: i�'. 1'>id4 i'4;"niG'r F' Ii{r." %1.Y•�n St'1_� ':e"t £t 1...t:_, <br /> Ale! <br /> ' 14.GENERATOR'S101FEROW8 CERTIFICATION:I hereby declare that the contents of this consignment are fully and socurately described above by the proper shipping name,end are dissited,packaged, <br /> j marked and labeled/placarded,and are in all respects in proper condition for transport according to applicable International and national governments[regulations. <br /> E GenerstoesrOHemr's P.rintedrryped Name Signature Month Day Year <br /> v § <br /> if <br /> ' ! F 15.International Shipments ❑Import to U.S. - ❑ po try <br /> Ex rt from U.S. Port of en /exit <br /> z <br /> Transporter Si nature for ex orts only): Date leaving U.S.: <br /> ¢ 16 Transporter Acknowledgment of Receipt of Materials <br /> W <br /> Trans�iter 1 Pnnted/Typed Name .�} � Signature � Mhonth Day Year <br /> ' N F'�1' i't(S� �.%e �IjlTl f'I[� f"�•,e��Y$i� �,/aLr% .�I'}.l-� V'w. r.14t. f..` <br /> aTransporter 2 Pnntedrryped Name Signature Month Day Year <br /> < <br /> 17.Discrepancy <br /> 17a.Discrepancy Indication Space <br /> ❑Quantity E]Type ❑ReslduB ❑Penial Refection ❑Full flefecGon <br /> ' Manifest Reference Number. <br /> > 17b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> J <br /> U <br /> LL Facility's Phone: <br /> 17c.Signature of Alternate Facility(or Generator) - Month : Day Year <br /> z <br /> c0 <br /> N <br /> W <br /> O <br /> 16;Designated Facility Owner or Operator.Certification of receipt of materials covered by the man'dest except as noted in Item 17a <br /> Printed/Typed Na"me Signature /) o'nth `Day j Yeyi <br /> 169-B1_( OV'6 10498(Rev.9/09) E T'RANSPOM ER#2. <br />