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NONHAZARDOUS 1:GeneraMrlD Nun bar E Page 1 Cf 3.Eme'gernrj Resp•Casa Phora 4.Waste Tracking Number F„ + <br /> WASTE MANIFEST � ,Yr AK)#J(�3 E "7G-7--s r . S <br /> b,Geno ato}r's Name and Melling Address : Genera!oeg SPe Address('f dlfferart then rnalfing aidr"s,.F <br /> CC-w <br /> f cr f , �., kE col�� .�• 1♦ I <br /> c�,�m�• .!,��,c,..,�y�.,r��-c`� sir•c a-� . Sal i-!x r.1 • <br /> i <br /> i 6 retor's�henet e.Y ..-�,1 ,. .. : <br /> TYenepo6r t DdrJP thy.)W'1e.% . 'U.S.FPA IO Number <br /> 7.Tr9nspoder2 C'dmpany erne ' - : US;EPA IQ MLObdr, 41 <br /> $,D`eslg ted Feollfty Name and Slts Address U,S•EPA ID Number <br /> � OY 14XV19,0AID MY APPLICABLE <br /> LE <br /> F s Phone, iii pni <br /> 9.Waste Shipping Name and Description 10..iontalners 11.T61a1 12•Urdt <br /> No. Type Quantify W114oL <br /> ir <br /> } 1typt .. r j;.< t��,1;3 � f rfi E.„ t��,...�,.•Crq , �. ,c%c�.:1,.� �;� t <br /> '-� •�}�i•..sa.aK(f�,.. :�,.�{• {,:•iii:�:r..: .i i <br /> Lu <br /> y7J 2, <br /> i•. 4. <br /> 134S0eoial3iat tlling Ins .i;ttons:and Additlonel InTomiatfon': " , ''-y� ,'?` r:: s:. a.{. , <br /> •tai. <br /> 14.GENERATOR'SIOFFEROR'S CERTIFICATION:I hereby declare that the contents of this consgrment are fully,and accurately described Gave by tie proper shipptrg name,and are classlfled,packaged, <br /> marked and labeled'placarded,and are In all respects fn proper condition for transport according to appileable tntemattona!and nationai govepmental regulations. <br /> Generator's Offeror's PrintedTyped Name Signature i f L Month pary Year <br /> ib.ln'ematlonalS mems "• --'-"""�-"" i <br /> ❑import to U.S. ❑EXpce.from U.S. _ Pori of entry,'at <br /> Transporter SI ature(for exports on)y): Date leaving U.S.: <br /> ¢ 16.Transporter,ACktirlajgmentof Rebel1 of Materials <br /> ''Transporter IPrfnted7ypedName "" ='�' n-S!grafu r fir. y— , ,,; -.•,�. .; •h�ogth.. _Da_} .Year 1 <br /> T•ansporter 2 Printedrryped NamaS gnature Mon"•+ Day Year i <br /> 17.D'sorepency <br /> 17a.Discrepancy Indlcai;cn Space ❑Ras: ❑Pelial Ra c or. <br /> ❑G anlicj 11 Type i:e <br /> )6 ❑FII Rejactio:r II <br /> 4tardfsat Reforenoo N-ember. f <br /> . 17b.Afte,ate Faclifty;or Generator) U.S.EPA 10 N;:mbe" <br /> U I <br /> LL FacVyts Phone: i <br /> "1 re.3fgna�;e.0 Alts atP E ..w 4Rf r'. <br /> MW-.h may. Year <br /> W <br /> lE nes grated Fad;N:y Omrar�ir Cperflt9r CB tifteatlQ C!'6 9lbt Of ma'.eaa;a:Ale ad by the nlaDlfdS:BXDap:Ba neie2 fa Rem V. �— <br /> P ny11 <br /> e1 <br /> Nama1 SYatu�a fAostn} D� reaPM <br /> p <br /> Jc <br /> 169-BLS-06 11979(Rev.9109) CENERATO R'S/8141PPER'S INITIAL COPY <br />