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169-BLC-0 6 10498 (Rev. 9/09) DESIGNATED FACILITY <br />NONHAZARDOUS <br />WASTE <br />t. Generator ID Number <br />� <br />� <br />2. Page 1 � <br />3. Emergency Response Phone <br />4. Waste Tracking Number <br />MANIFEST <br />. K L)l/C�r C` <br />pC) L jg <br />06013 <br />5 Saw s Nam< and hta t ng Address S <br />rnGenerators Site Address (if different <br />than mailing address) <br />/ Cartme k; 6LV4– <br />S/ S30 3i?I{ <br />Generator's Phone: 1 <br />6. Transporter 1 Company Name <br />U.S. EPA ID Number <br />7. Transporter 2 Company Name <br />U.S. EPA ID Number <br />B. Designated Facility Name and Site Address / r ;A ( <br />! u ., � c,. j 1CeL�/C- • n��, art . <br />U.S. EPA ID Number <br />F�I�'sPhonej ` )'I4(( (C -f Ge. <br />- - . �56—S 2 <br />r <br />9. Waste Shipping Name and Description <br />10. Containers <br />11. Tolal <br />12. U mt <br />No.Oua <br />Type <br />nirty <br />Vitt Not <br />cc <br />' Fx C II• ( -z Ct -e.0 t/ c e- - -r, s vl �, r/ c <br />— <br />L A 7£ <br />W <br />--- <br />W <br />2. <br />l <br />3 <br />13. Special Handling InstrucGau and Additional Information <br />q; 7x <br />14. GENERATOR'SIOFFEROR'S CERTIFICATION: I hereby *cCare teat the contents of tris ccrWment are fuly and accurately described atom <br />by the proper shipping name• and are classified. packaged. <br />marked ars? labekd'pfacarded, and are in all respects in proper conditm for transport acro drrg to ag,4icabnd le raema I anabonal governmental reguiaG <br />- -- <br />GeneratorsOrorsPrnted?ypedName Signature �rr` <br />Jot S5y /� ALR i <br />%� <br />` <br />AApnlfl /ay yea <br />�, <br /><' <br />E/� <br />J <br />�- <br />15. International Shipmkits <br />❑ Import to U.S. ❑ Expert from U.S. Port of entry exit: <br />= <br />Transporter S: nature fa expons on) Dale!eaving U.S <br />W <br />16, Transporter Acknowledgment of Receipt of Materials <br />¢ <br />Transporter 1 P riled Typed Name Signature <br />Month Day Year <br />rn <br />< 1I <br />Transporter rinfe67yped trame u:e <br />Month Day Year <br />cc <br />F <br />17. Discrepancy <br />17a. Discrepancy Indication Space <br />❑ Quantity ❑Type ❑ Residua <br />❑Partial Rejection <br />❑Full F9ieclWn <br />Manifest Reference Number. <br />17b Alternate Facility (or Generator) <br />U.S. EPA ID Number <br />7 <br />U <br />u4 <br />Faclity's Phone: <br />uuj <br />Q <br />17c. Signature of Alternate Facility (or Generator ) <br />Month Day Year <br />Z <br />C7 <br />I <br />W <br />O <br />18. Desgna;e7 Fa0ily O�mter or Operator Cerbfeatan of recepl of matQrras caered try trv_ rr2nifest except a; noted in horn 17a <br />Pwted;TypeP Name \ - / Signature <br />Month Day Year <br />169-BLC-0 6 10498 (Rev. 9/09) DESIGNATED FACILITY <br />