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NON-HMiWDOU5 I.Generator ID Number 12.Page 1 of'3.Emergency Response Phone �4.Waste Tracking Number r <br /> WASTE MANIFEST i &Y� <br /> 5.Generator s Name and Mai ng ddress — Generator's Site Address(rTdrfferent than marng address) <br /> W <br /> l ii el'L ,fi t l <br /> .5 a�, <br /> Generator's Phone: <br /> 6,Transporter 1 Company Name <br /> 7 U.S EPA ID <br /> FT�;�rter 2 Company Nae:e f - } i1 <br /> �.1 r. <br /> U S EPA ID Number <br /> 8 Designated FadTay Name and Site Address <br /> CS .�F�li <br /> }1 �� Sc'k t��� U.S.EPA ID Number <br /> � f <br /> �F aaT, sPhone. 7,,)-7 <br /> 9.Waste Shipping Name and Description' _ ip Contamers 11.Total12.Un$- <br /> 1 No. Type Ouantlty W11Vol <br /> � � I <br /> Lu <br /> a l <br /> �3. <br /> 13.Special Handring instructions and Addrlional Information <br /> VA aTAds sfi,,fr 119.0 <br /> pt" y ' <br /> 14,GENERATRR'SlOFPERaR'S CERTIFlCATIRN:I r� � ��' �� <br /> marked end le6ele FFERerded,and ora in ell �r declare that the cw wts of this consignment are h4 and a=m*descdbed above the - <br /> �P�s I proper condition for transport accardng to app c2 a into and by P tap aig name,and are classified,packaged, <br /> Generator' roes Print' T e + gove/rnmmeental�regut ft s. <br /> Month 1 �r Day Year <br /> 15.Imematioral 5hipmeri� <br /> ❑lmpo o U.S. El Export from U S. 1 ;' Port of r <br /> Tran iter Sl tura lfor a its zo- <br /> 16.Tnursporter AcWMedgment of Receipt of Materials Date feu U.S.- <br /> Transputer 1 PrIntedfryped Name r <br /> Month Day MW <br /> 7�j" PrintedlTyped Name R :`. [:? . <br /> Mordh Day Year <br /> —i-7a-Disaepan�y Indic%—n Space ❑Quantity ❑Type ❑Residue Partial RejecSon ❑Full Reja6an <br /> 17b.kemate Facility(or Generator) Manifest Reference tVum6er <br /> ---FS—EPA—ID Number <br /> U <br /> a <br /> ftArfs Phonr: <br /> f 17c.Signature of Aitomate Facility(er Generator) <br /> { Month Day Year <br /> Lu <br /> k1 e.Designated Fad ly Owner or operator Certification of receipt of materials covered the manifest <br /> Printedlryped Name �' ePt as noted in Nem 17a <br /> f <br /> Month Day Year <br /> y 6"LC-O 6 10498(Rev.9109) ' ''' e i <br /> COPY <br />