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r . f 1. <br />169-BLC-0 6 10498 (Rev. 9109) 4 ' DESIGNATED FACILITY TO GENERATOR <br />a". Pa/ge t of 3. Emergency Response Phone <br />NONHAZARDOUS 1. Generator ID Numberry <br />4. Waste Tracking Number l <br />c� `� <br />WASTE MANIFEST 00 D d�—)7) W. i O O g s <br />669613 <br />5. Generator's Name aro Mailing Address „ Generators Site Address (d different than mailing address) <br />� Eli 4f 1 <br />J 12 vt'tonr+1eltiC, <br />Ce-rh,cI& G-vG. <br />�gl. <br />oTSPh3oreq`/ Cc,. �i5?r�`� <br />�f <br />6. Transporter t Company Name <br />US EPA ID Number <br />4t K <br />1 CAFoaolo31ol <br />7. TransPorter 2 Company Name <br />U.S. EPA ID Number <br />8 Designal Facility Name and Site Address , } <br />v i S on'S 1'd'!c+7re— <br />U.S EPA ID Number <br />f I VA . <br />4l4, 4�� X06 <br />FS e.0 rF L n pCr.- 32aa 's Prme: <br />9. Waste Snipping Name and Description <br />11 Total 12. Unit <br />.._ ''y Iv1 Vol <br />_ :e <br />g <br />'EXCIL,deg r-tcyclxble ��all'ill�� <br />(P&IId <br />121000; <br />P <br />z <br />W <br />2. - <br />3. <br />4. <br />13. Special Handling instructions and Ada tonal Intomlatton <br />I . I, 19 'x P4Itf s <br />14. GENERATOR'SIOFFEROR'S CERTIFICATION: I hereby cedare that the contents of ilii% rmsgnmcnt are fully and accura" described above by the proper shipping name, and are dasstied. oackaged <br />marked and labeled placarded, and are in all respeds in proper conditron fa transport according to applicable international and national governmental regulations. <br />Generator sOtferors Pnntedrryped Name Stgnatur <br />Month Day Year <br />'j6stpl. SI va <br />1o6 11L 1 B <br />15. International Shipments <br />❑ Import to U.S. Export from U.S Pod of entryleml: <br />TranspWer Signature (for exports orgy): Date Ieav,ng U.S.' <br />It <br />Lu <br />16 Transporter AclulmNedgmerit of Receipt of Materials <br />—. <br />0 <br />Transporter 1 PnnledTypeo//Name Sigrre <br />—7 <br />Montt Day year <br />rn <br />a <br />Transporter 2 PnntedRyped Name Signature <br />Month Day year <br />17. Discrepancy <br />17a. Oisaepancy ln(bcation Space F-1 Ouanay ❑ Type ❑ Res due <br />❑ Partial Rejection <br />❑ Fua Reject. <br />Manifest Reference Number. <br />J <br />17b. Alternate Facility (or Generator) <br />U.S. EPA ID Number <br />U <br />ua. <br />Faciliy's Phone: <br />w <br />17c. Signature of ARemate Faality (or Generales) <br />Month Day Year <br />z <br />2 <br />rn <br />w <br />a <br />18. Dosgnated Faalrty Caner or Operator. Certification of -eceipt of materials rovered by the man'est except as noted n Item 17a <br />Pnn190(Typed Name . 'Kg;latwe <br />' <br />/Da��t Year <br />1/4 L \ y\ • <br />ills Lx✓ <br />169-BLC-0 6 10498 (Rev. 9109) 4 ' DESIGNATED FACILITY TO GENERATOR <br />