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<br /> NOWHATARDOUS . 1,Generator ID Number 2.Page 1 of 3.Emergency Response Phone 4.WasieTracking Numbs
<br /> WASTE MANIFEST
<br /> 5•Generalofs Name and Mailing Address f� General is Site Address(it different than malting address)
<br /> ' eneret a P
<br /> e 7ransportay 1 mpany Name r U.S.EPA ID Number
<br /> "I eZt1j 41 701CI
<br /> .7.Transporter 2 Compan ame U.S.EPA ID Number
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<br /> 8.Designaled,Facility Name and Site Address / U.S.EPA ID Number
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<br /> aci a Phone: r
<br /> 10.Containers Total .,
<br /> 9.Waste Shlppirlg Name and Description r.;,. '
<br /> No. Typo' Quantity `
<br /> WetV�•r'•',*.!'1S1'� '•V6/L�j �I r7�iJ i+-y.7ff M ./'k r_y`'' ',r �r ,34,4i,` a T�`'^yc',k ,A
<br /> O 1��v7'c � ,l/X.y '•'-� � a'�r�a'��y't�+'����'�sy,+t�fin r�
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<br /> MON
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<br /> 13,S*rlis', idling iWiucgonsandAdditfonalIniormallon
<br /> � t'irr.1f7 :
<br /> 14.GENERAMOR'SIOFFEROH' TIFICATION:I hereby declare that the contents of this consignment are fully and accurately described above by the proper shipping name,and are closslfied,packaged, .
<br /> mark an labeled/placar�e)r&"N-are In all respects in proper condition for transport according to applicable Intemallonal and national goys mental regulations.
<br /> Gene $(Of fors Printed/Typed Name Sigre- r ` Month 'Day year*.
<br /> rr t5.in -agonal Sh(pmenta y
<br /> ❑Import to U.S.' Export from U.S. '' �•'°'Port of entry/axil:
<br /> -Transporter Signature fore orts org : Date leaving U.S.:
<br /> 18,Transporter Ackn6wledgmenl of Recelprof Materials ^
<br /> Transporter 1 Printed/Typed Name, ! �uignalure <,v Month Day: '.Y
<br /> 7ransporter2 Pdnled/ryped Name "Signature r Month Day :..Year
<br /> 17.Discrepancy.. ..
<br /> 17e:Discrepancy Indication Space
<br /> 0 Quanlit'y ❑Type ❑Residue ❑Partial Rejection ❑Full Rejection 7:
<br /> NT Manifest Reference Number,
<br /> 17b.Alternate Facility(or Generator) U.S.EPA ID Number
<br /> LL Fadillys Phone:
<br /> 17o.Signature of Aitemale Facility(or Generator) Month Day Year
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<br /> 18.Designated Facility Owner or Operator,Certificallon of repeipkgf materials covered by the manifest,except as noted in Item 17a
<br /> Pdnledfiyped Name y Signature _ '�'' Month Day, year.
<br /> 169-BLC-0 6 10493 V.9/09) ' '- '-"'•
<br /> COPY
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