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NON-HAZAROOUS 1.Generator ID Numberaq <br /> 2.Page 1 of 3, rnergency Response['hone 4.Waste Tracking Number <br /> WASTE MANIFEST i -"" L�'6 , I �UVD F <br /> 5.Generator's Name and Mailing Address g{I���S � � Herat s Site Address(if different than mailing atldress} <br /> { s � s CV[+ <br /> Generators Phone: <br /> 6.Transp r 1 Company Name U.S.EPA ID Number <br /> I 7 Transporter 2 Co any Name ` <br /> U.S.EPA ID Number I� <br /> k 8.Designated Facility Name and Site Address�g /'_ 1 U.S.EPA ID Number <br /> 1 ba�li E• rtJ,A G L , <br /> Ii 's Phone: <br /> .I <br /> 9.Waste Spipping Name and Description 1 Q.Containers 11.Total 12.Unit <br /> No. Type Quantity Wt.Nol. <br /> ' �tv�rs w IIS&03f Ilk+t446C' 14 <br /> cc <br /> Lu <br /> �. <br /> Z <br /> z [v$tsa� OoftvIDA <br /> 3 <br /> I <br /> 4. <br /> 13.Special Handling Instructions and Additional Information <br /> JWr <br /> 14.GENERATOR'S10FFEROR'S CERTIFICATION:I hereby declare that the contents of this consignment are fully and accurately described above by the proper shipping name,and are classified;packaged, <br /> marked and labeled/placarded,and are in all respects in proper condition far transport according to applicable intemational and national governmental regulations. <br /> Generators/Offeroes Printed/Typed Name Signature Month Day Year <br /> -r 15 Intemahp al Shipments Fri Irr <br /> Z ElImport to U.S. ❑Export tram U.S. Port of entrylexii: <br /> Trans orter Si nature for ex orts onl : Date leavin U.S.: <br /> LU <br /> 16 Transporter Acknowledgment of Receipt of Materials <br /> Transporter 1 Printe ed Name Signature <br /> O Month Day Year <br /> aa r <br /> Transporter 2 Printed)Typed NameI Signature <br /> F Month Day Y ar <br /> 17 Discrepancy <br /> 17a.Discrepancy Indication Space <br /> ❑Quantity ❑Type ❑Residue ❑Partial Rejection ❑Full Rejection <br /> 1 <br /> 1 � 17b.Alternate Facility{or Generator} Manifest Reference Number: U.S.EPA ID Number <br /> J <br /> U <br /> rat Facility's Phone: <br /> H17c Signature of Alternate Facility(or Generator) Month Day ' Year <br /> 4 <br /> Z <br /> � I <br /> �a <br /> 18.Designated Facility Owner or Operator:Certification of receipt of materials covered by the manifest except as noted in ltom 17a <br /> Printedffyped Name Signaim Month Day Year <br /> bi <br /> U El <br /> 169-SLC70 6 10498(Ren.9109.) DESIGNATED FACILITY TO GENERATOR <br />