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MON-HAZARDOUS 1.'Generat6r um <br /> IR Number 2.Page I of 3.Emergency Response Phone 4.Waste Tracking Number <br /> I <br /> WASTE MANIFEST t <br /> 3. 4 C,1� 0 r- TD) <br /> S.Generators Name andailing AdtSress Generator's Site Address(it different than mailing address) <br /> "Ar <br /> rn." , ". SMOINV" F'.'R F-;, Irv, <br /> 51IGG PACIFIC AVIETWE <br /> 57"157 57 SUVII-F 221] <br /> ST( '-1i ST 00,70d r,",'A Q;52C',7 <br /> Generators Phone: X)a! AMIM <br /> 6,Transporter 1 Company Name U.S.EPA ID Number <br /> NKCI 0 !1 (j <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> Oaf <br /> 8.Deal EIR <br /> noted Facility Name and Site Address U.S.EPA ID Number <br /> P15TR0 HILLS LANDRILL. <br /> still"Uk] CITY rA N50!5 <br /> Facilh es Phone: IN' 1122-11+N13 <br /> 10.Containers 11:Total 12.unit <br /> 9.Waste Shipping Name and Description <br /> No. Type Quantity WtJVcI. <br /> z 2. <br /> 3. <br /> 4. <br /> 13.Special Handling Instructions and Additional Information <br /> ,�S41 <br /> CIA_ ".16-7112 <br /> INC 1160S VERV.111 IM.ITV ALAI.-IM71, �,zN C4-'Sv. <br /> 14.GENERATOR'SIGFFEROR'S CERTIFICATION:I hereby declare that the contents of this consignment we fully and accurately described show by the proper shipping name,and are classified,packaged, <br /> marked and labeled/placarded,and are in all respects In proper condition for transport accorcring to applicable International t 11 <br /> I and national governmerdal regulations. Day, Year <br /> Generatmos/Offeror's Pdnted Signatufff Month <br /> rryped Namb <br /> 15.1mernattanal Shipments 0 Import to U.S. 0 Expoel from U.S, Pon of entry/exit <br /> Transporter Signature for exports only): Date leaving U.S,: <br /> 16.Transporter Acknovvledgment of Receipt of Materials <br /> Month <br /> TrAnsporler I PrinteclTyped fame Signature <br /> t1 1. 1Y25' <br /> �4 <br /> 0 <br /> CL Month Day Year <br /> 2 T parer 2 PrintedfFyped Name 81 Alum <br /> Q T— J <br /> Is 7 <br /> IT Discrepancy <br /> 17a.Discrepancy Indication Space F1 Quantity EIType ❑Residue El Partial Relmilon ❑Full R.ejection <br /> Manifest Reference Number, <br /> 17b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> X FaciliVs Phone' <br /> 0 17c.Signature­ of Alternate Facility(or Generator) Month Day Year <br /> w <br /> z <br /> 18.Designated lly.qKtar oar 9perator Certification of receipt of materials covered by the manifest except as noted In Item 17a <br /> Signature n ay ar <br /> PrntedrTyped Name I., <br /> 169-BLC-0 6 10498(Rev.9/09) TRANSPORTER #2 <br />