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NON-HAZARDOUS I 1 Generd!ar iD Number 2,Page 1 of.�,Emergency Resporwse Phone 4.Waste Tracking Number <br /> WASTE MANIFEST J <br /> 5 Generator s Name and Matting Address <br /> Genw=ft&WAddress Cd dMarent than maaing address) <br /> pe,� y Er b ( I l X06 4 r 11/0 f <br /> e.Transporter 1 G1 G pang Name <br /> U.S EPA 10 Number <br /> �71X <br /> Transporter 2 Company oma ' U.S.EPA 10 Number <br /> 8.gesignated FaaTity Name and Site Address <br /> Coles U.S.EFA IQ Number <br /> ��'•Wl� <br /> I 6,;L&'�rr�•�u� �,rG� <br /> ad1rY5 Phone. Gr ,S f! �L�C/J g3307 � �, � �7->• <br /> 9 Waste Shipping Name and Description 1a Containers it.Total 12.Unit <br /> V R�AL fT F— Na. Type fluantiry WtNd. <br /> x <br /> ° 1 <br /> 3. <br /> 13 Special Handling Insinrctians and Add nou Information <br /> 14.GENERATOR'SA?FFEROR'S CERTIFICATION:I hereby declare that the carttents of this consignment aro fully and eccurdtely described above by the proper shipping name,and are classified,packaged. <br /> marked and labeledlptacanded,and are In all respects In proper cargition for transport according to appkCabte krtematiorW and,� govemmental nom. <br /> Gtra•ata7; eror's PrirderllTyped Name 5' Month <br /> Day Year' <br /> 15.IntemaL'orrai Shipments P la ,-I A _,� [Arj 1/7 <br /> ❑Impart to U.S. ❑Evort from U.S. Pon of entrylerdt <br /> T er5' ature'fore�ora <br /> x t6.Transporter Acknowledgment of Receipt ofterials Date lead U S_ <br /> Transporter t PdnledTyped Name <br /> 2 1 W"e i T /Day bYear. <br /> N � <br /> qC: Transporter 2 Printedrfyped Name Sigraturs <br /> ___00 Mort Day Year <br /> 17 Discrepancy <br /> 17a Discrepancy Indkafia-.Space <br /> ❑Quantity ❑Type 0 Residua ❑Partial Rejection ❑Full Rejection <br /> 17b Altemafs Fad&j for Generator Manifest Aelerence Number <br /> US EPA 10 Number <br /> U <br /> w Faa7ityr's Phone. <br /> 17c 5ignatrtre of Alternate FaaTiry{or Genera" <br /> a Month Day Year <br /> 1 <br /> 1 1 B.Designated Facility Owner or Operator CertiflraSon of receipt of materials covered by the manifest except as noted hL fenrl7a . <br /> F Print <br /> ,� Signature <br /> Yea! <br /> 169-BLC-0 6 10498(Rev.9109) <br /> TRANSPORTER##2 <br />