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NONHAZARDOUS 1.Generator ID Number 2.Page 1 of 3.Emergency Response Phone< 4.Waste Tracking Number <br /> WASTE MANIFEST, °»'' Al_ <br /> .•: <br /> 5.Generator's Name and Mailing Address Denerators Site Address(ffdifferent than mailing address) <br /> f3ol, <br /> Er1 , 14Al r��t� ��t� .>Jr <br /> Gene a or's Phone J 47,. J <br /> 6.Transporter 1 Company Name U.S.EPA ID Number <br /> 7.Transporter 2 Company Name _ r T r U.S.EPA ID Number <br /> 8.Designated Facility Name and Site Address U.S.EPA ID Number <br /> r <br /> Facility's PhonePLO L Z')2 <br /> 9.Waste Shipping Name and Description <br /> 10.Containers 11;.Total 12:Unit <br /> No: Type Quantity. •Wt.Noi. <br /> 2. <br /> 13.Special Handling Instructions and Additional Information <br /> A As-A—eJ SAO, <br /> bk,/r <br /> 9 r uS <br /> .�y-3�� / r • <br /> "fir, ) ¢ <1 '�r •_ <br /> NNN 'v-,'A4... <br /> 14,GENERATOR'S/OFFEROR'S CERTIFICATION:thereby declare that the contents of this consignment are fully and accurately described above by the proper,lt�p game,antl are classified;packaged, <br /> marked and labeledlplacardad,and ere in all respects In prop+er'condition for transpo)t•acwording to applicablelntemjtf3 al;and natf*Jilovemmental regulations at >,°;. <br /> Generator, q eror's'Printed/T a Name Si <br /> -tjlgnat t Month Day Year. <br /> 15:Interna Ionai Shipmenfs <br /> ❑ - <br /> Impoo U.S. ❑Export from U.S. Port of enirlex t <br /> Transporter Signature for exporfs only):, Date leaving U.S.; <br /> w 16,Transporter Acknowledgment of Receipt of Materials <br /> Transporter 1 PdntedfTyped Namev-�" t Signaiare Month Day Year <br /> hill) , <br /> hnt <br /> rieq/Typed Name Signature �,.�"" , f ;c <br /> Month Day 'Year <br /> 17,Dlscrepancytr,,fz+�, t ' <br /> 17a.Discrepancy Indlcailon SP cb r <br /> 1, Quantity ElType ❑Residue ❑Partialection Re <br /> Rejection 171 <br /> FUII!Rejection <br /> Manifest Reference Number: <br /> 17b.Alternate Facility(or Generator) U:S.EPA ID Number <br /> -J <br /> V <br /> LL Facility's Phone: <br /> w 17c.Signature of Alternate Facility(or Generator) Month Day Year <br /> Z <br /> 13 <br /> 18.Designated Facillty Owner or Operator.Certification of receipt of materials covered by the manifest+except as:noted in itemi:l7a, <br /> Printed/Typed Name r SI nature f <br /> 1J, f 9 7 Month Day Year <br /> r �.>c'r r•�, r a.a:t� 't� r 1 �}' r r <br /> r,.J th s <br /> 169-BLC-0'8 10498(Rev.9/09)' r'r f �'� COPY <br />