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z <br />Illy-tiLU-U 6 10498 (Rev. 9/09) -/DESiGNATEi) FACILITY TO GENERATOR <br />NONHAZARDOUS <br />1 Generator ID Number <br />S_A? 6 <br />2. Page 1 of <br />3. Emergency Response Phone <br />4. Waste Tracking Number <br />WASTE MANIFEST <br />C A Q 0 O� 9 <br />g21q 0 qs <br />SQ t 3 <br />5. Generates"s Name and Matting Address Generator's Site Address (if diiferent than mailing adiressl <br />Vr ara�l///ViE1lfi6.I J •1G . <br />)� /��il <br />1SS 2 ('0` r'mcl o av�, <br />q <br />y5/53a 3y7y <br />Generators Phone. Trac C p`- `15,36,11 <br />6. Transporter i Comparryr Name U.S. EPA ID Number <br />E , lir~I 1C4 6 o q G3 ! Ca <br />7. Transporter 2 Company Name U.S. EPA ID Number <br />S. 3esgra! zd Fact,' Name and 5!e Ad -mess til j I !+ % Q PiG �/(� 1.n Pa Y �y(. U.S. EPA ID Number <br />9. Waste 5h,- -_ •came and Description <br />10. Containers <br />11. Total <br />12 Unk <br />No. <br />Type <br />Guar City <br />WtNd. <br />I <br />l EXClvd <br />lod !uf� <br />cr <br />G.q ec PAS/,/IPAS/,/i <br />UJ <br />Z <br />W <br />2. <br />I <br />i <br />I <br />3 <br />13SpecialHandling Instructions and Additional Information <br />S/( tic S <br />-flet <br />14. GENERATOR'S/OFFEROR'S CERTIFICATION: I twretry declare that the contents of thus consignment are fully and accurately descnbed above by the proper shipping name. and are classified, packaged. <br />marked and labefedptacarded. and are in au respects in proper condition for Transport according to applicable mlemational and national govemmenwl aeons. <br />Generalor's,09femrs Printed/Typed Name Signature Month Day Year <br />Ive, <br />I xos I a5 3 <br />.J <br />Z <br />15. International Shipments <br />❑ Import to U.S. ❑ Export from U.S. Port of entry!exit: _ <br />— <br />Transporter Sionalure for expons only): Date leaving U S.: <br />W <br />_ <br />16. Transporter Acknowledgment of Receipt of Materials <br />Transporter 1 Printed7yped Name Signa Month Day Year <br />��—� <br />a <br />W <br />N <br />r/1 �� c r ri I — 1.5 O <br />Z <br />: ransporter 2 PnntedTyped Nwne Signature Month Day Year <br />c <br />Ia <br />t- <br />17. Discrepancy <br />17a. Discrepancy Indication Space ❑ F 1 Ouant�ar ❑ i ;o_ ❑Fes^_ue ❑Partial Rejection ❑Full Rejection <br />I,fandest Reference Number. <br />. <br />� <br />171b. Alternate Faciliy (or Generator) U.S. EPA ID Number <br />J_ <br />V <br />ua <br />Facility's Phone: <br />Lu <br />17c. Signature of Allemate Facility (or Generator) Month Day Year <br />Z <br />t7 <br />N <br />W <br />O <br />' <br />18. Designated Facility Owner or Operator. Certdtcation of ecelpl of materials covered by the manifest except as noted in Bern 17a <br />Printed?yped Name Signature / , Si^a Monty Day Year <br />�; . ; <br />ol W <br />� <br />Illy-tiLU-U 6 10498 (Rev. 9/09) -/DESiGNATEi) FACILITY TO GENERATOR <br />