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NON HAZARDOUS 1,Generator ID Number 2.Page 1 of 3:Emergency Responsephone 4.Waste Tracking Number <br /> WASTE MANIFEST a 4 r <br /> 1 �$ t, epi , ;... � •yr,� � ,;r ( {` : .e' „� <br /> 5.Generator's Name and Mailing Address Generato s Sits Address(if different than mailing address) ` r <br /> y �}11�rt �,$r/ <br /> Y��t"I.�. J.fyj t3 ✓�b1 rni'(.i ew.".ii`'S ('r j.�•} f";�': .l . w. :3 Tie k <br /> Generator's Phone: <br /> 6.Transporl9f,1 Company Name U.S.EPA ID Number <br /> Lit rrF :'1Si:r' f ylrv.:•t�' f 3`!y'��$ �.:1„�'('>f614'i <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> 6.Designated Facility Name and Site Address tt j :,tool 4•,t�,t. ,+ U•S.EPA ID Number <br /> J,: <br /> 'Facility's Phone: _ 1,M <br /> 9.Waste Shipping Name and•Description <br /> 10.Containers 11.Total 12.Unit <br /> No. Type Quantity Wt.Nol. <br /> t) <br /> y <br /> a <br /> w 2. <br /> ” <br /> 3. <br /> y # <br /> J <br /> 4. <br /> <:l <br /> 113 5peofai Intoa <br /> Handiigg Instructions and Additional mat op <br /> �r <br /> 41 <br /> 14.GENERATOR'S/OFFEROR'S CERTIFICATIONi I hereby declare that the contents of this consignment are fully and accurately described above,by the;propershipping nems attd afe'classiffed packaged p <br /> `marked and label4lacatded,and are In all respects in proper condition for transport according to,applicable intemaUona[and national govemmental,regulatfons. 4.'' •';'; <br /> Generator's/Offeroes PnntedlTyped Name SI nature <br /> ;) g� Month DM eat <br /> `;.j 15.International Shipmentso <br /> nom, <br /> F Imp 0a to U.S. ❑Export from U.S. Port of entry/ex�l <br /> Transporter Si nature.for exports only).. , Date leavin"it1 S. r <br /> w 16.Transporter Acknowledgment of Receipt of Materials <br /> oTransporterl-P'Ate` ypedNave r Signature Month Day xYear', <br /> Q Transporter 2 Printed/Typed Name Signature WMonth Day Year <br /> 17.Discrepancy ; <br /> 17a.Discrepancy Indication Space <br /> ❑Quantity 1 Type ❑Residue ' DPeitial:ReJection Y ..,y, Fuli Rojectiom; <br /> Manifest Reference Number. " <br /> 17b.Alternate Facility(or Generator.) U.S.EPA IDNumber <br /> ua. Facility's Phone: <br /> F17c.Signature of Altemate Facility(or Generator) Month Day Year <br /> z <br /> My <br /> 16.Designated Facility Owner or Operator:Certification of receipt of materials;covered by the manifest except as noted m tem 17a _ <br /> Pdn'ted/TypedName . <br /> �f Signature Month! Day YeaC, <br /> `169-BLC-0 6 10498(Rev.9/09) COPY..` <br />