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u 1.Generator ID Number 2.Page 1 of Emer ency Response Phone 4.Waste Tracking Number <br /> NON HN -5--7/q-5-- ?6(.5�t�j <br /> WASTE MANIFEST (, (� Y: L`)- <br /> 5.Generators Name aMalting Address Generato s Site Address(if different than mailing address) <br /> 1391 K1JX/nd A-& <br /> 11 , 4 / <br /> Generator's Phone: Y 7 U.S.EPA ID Number <br /> 6,Transporter 1 Company Name <br /> c L� <br /> •2 <br /> U.S.EPA ID Number <br /> 7.Transporter 2 Company Name <br /> U.S.EPA ID Number <br /> 8.Designated Facility Name and Site Add�r}ess' f t n <br /> ��(/�L�✓ .7GL�- �� <br /> Facilit's Phone: L 10.Containers 11,Total 12.Unit <br /> 9.Waste Shipping Name and Description No. Type Quantity WIJVoI. <br /> 1. <br /> a <br /> W �a <br /> z <br /> Lu 2. <br /> 0 <br /> 3. <br />[ 4. <br /> 13.Special tiandiing Instructions and Additional Information 1r �!/; �'® <br /> 14.GENERATOR'S/OFFEROR'S CERTIFICATION:I hereby declare that the 417, <br /> contents of this consignment are fully and curately described above by the proper shipping name,and are classified,packaged, <br /> l marked and label ed/pI ded,and are in all respects i prop r condition for transport according to applicable intern to al and nation governmental regulations. <br /> fffl <br /> Signa r Month Day Year <br /> Generator rors Print eyiMtame -7 <br /> -.r 15.International Shipments Impo o U.S. ❑Export,from U.S. Port of ant exit: <br /> Date leavin U.S.: <br /> Trans orter Signature for ex orfs oni : <br /> cc 16.Transporter Acknowledgment of Receipt of Materials Month Day YearLU <br /> ' <br /> Transporter 1 Printedrryped Nam@' '° <br /> a Month Day Year <br /> Z Transporter 2 PrintedlTyped Name Signature <br /> cc <br /> 17.Discrepancy <br /> 17' Discrepancy Indication Space ❑Residue ❑Partial Rejection ❑Full Rejection <br /> El Quantity ❑Type <br /> Manifest Reference Number: 1 <br /> U.S.EPA ID Number <br /> r 17b.Alternate Facility(or Generator) <br /> J � <br /> U <br /> LL Facility's Phone: Month Day Year <br /> LO 17c.Signature of Alternate Facility(or Generator) <br /> tLl <br /> ah <br /> z <br /> co <br /> Lu <br /> o <br /> 18.Designated Facility Owner or Operator:Certification of receipt of materials covered by the manifest except as noted in Item 17a Month Day Year <br /> Printed/Type Name Signet rlr� <br /> ,9 Uf G� c�— <br /> 169-BLC-0 6 10498(Rev.9/09) <br />