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-oLI.,-U o tUwan (nev. t$1Ub) i f GidATED FACILITYTO GENERATOR <br />NON -HAZARDOUS <br />WASTE MANIFEST <br />1. Generator ID Number <br />Cf1 f-CC©=A7(. <br />2. Page 1 of <br />I ! <br />3. Emergency Response Phone <br />I ifs t 5,3? " <br />4. Waste Tracking Number <br />011013 <br />5. Generators Name and !.Sailing Address.SC le &ivi ro nmwn4p, ( �C.. Generators Site Address (it different than mailing address) <br />-75-s--7-75-s--7Cmr-- /& a.v f., <br />I(,p y I%G..0 y C4" '15-.300 <br />I r t em, <br />r3 h3 <br />6. Transporter 1 Company NameU.S. <br />�d <br />EPA ID Number <br />C h, 0 2 <br />(JL) G) <br />7. Transporter 2 Company Name <br />U.S. EPA ID Number <br />6. Designated Facility Name and Site Address j — v"r-Onivrex f l ' <br />U.S. EPA ID Number <br />/68o s. ca --.-no r2ea( ft Aq <br />.5 �crnord�.�c�,. �� jos <br />'s <br />G'�g�eaoa�o3 X09 <br />Facia, Phone: <br />9. Waste Snipping Name and Description <br />10. Containers <br />11. Total <br />12. Unit <br />No. <br />Type <br />Quantity <br />ffl va <br />GS�d <br />oo <br />a <br />f,(er0�0� CGZ <br />C. I <br />` <br />! <br />Z(1f1►�lrZrSa-( I,rJQ-,$j�� <br />300 <br />P <br />us <br />Dr <br />13. Special Harding Instructions and Additional Information <br />4.c Mlc d <br />4.3 ;I,X <br />14. GENERATOR'S CERTIFICATION: I certify the materials described above on this manifest are not subject to federal reguiatrms for reporting proper di of Hazardous Waste. <br />Generators/Otferors Pnnled?yped Name Signature 9n <br />Month Day Year <br />O 113 <br />-1 <br />z <br />15. International Shipments <br />❑ Import to U S. ❑ Export from U -S. Port of entry/exit <br />— <br />Transporter Sionature, (for exports only): Date leaving U.S: <br />cc <br />16. Transporter Acknovledgmenl of Receipt of Maerials <br />Transposer t PrintedT Na Signat re <br />1tr� <br />L <br />- <br />Month Day Year <br />N <br />- -) (1 Ll CCs-- 1 I <br />F <br />Transporter 2 PrintedTyped Name Signatur <br />Month Da r <br />ccY <br />17. Discrepancy <br />17a. Discrepancy Indication Space <br />❑ Quantity El Type Residce <br />❑Partial Rejection <br />❑ Ful Reiecticn <br />blandest Reference Number: <br />J. <br />17b. Alternate Facility (or Generator) <br />U.S. EPA ID Number <br />U <br />tai <br />Facility's Phone: <br />w <br />r <br />17c. Signature of Alternate Facility (or Generator) <br />Month Day Year <br />a <br />Z <br />N <br />W <br />D <br />18 Designated Fate iry Ovmer o, Operator. Certification of receipt of materials covered cry the manifest except as rated in Item 17a - <br />PrintedrTyped e ' Sg to <br />MorMh You <br />-oLI.,-U o tUwan (nev. t$1Ub) i f GidATED FACILITYTO GENERATOR <br />