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Please print or type. (Form designed for use on elite (12-pitch) typewriter.) <br /> NON-HAZARDOUS 1 . Generator ID Number 2. Page 1 of 3. Emergency Response Phone 4. Waste Tracking Number <br /> WASTE MANIFEST t %Ai 11lX11i1.' 1 ;(K- '.t4V 4114 <br /> I : hus <br /> 5, Generators Name and Mailing Address Generator's Site Address (if different than mailing address) <br /> i;1,NV F AB :�1LtF OF041A <br /> 114 W LAI } FiA01I RD <br /> I -A 1 HtfOV . ( ;A 'J4)AX) <br /> GeneratorsPhone!Xt. 24044. / IV <br /> 6. Transporter 1 Company Name U.S. EPA ID Number <br /> AN* `4ItW4 VAl Lll : Y WANE 0111, . IN <br /> 7. Transporter 2 Company Name U.S. EPA ID Number <br /> VVA 1L: `7CXUIK*A1 ; , : t**L:AXN) I itW24 <br /> 8. Designated Facility Name and Site Address U.S. EPA ID Number <br /> � �k: AIF ieMb _}X , t :O#tIXNA . t I .i : _ t;AF )u$1'1.-tttdltl`i, <br /> t :i `j YYFftik t<tK KHI ) . <br /> ti 44 'Pi- 10 1';0ftD0VA, (7A <br /> Facility's Phone,'-i St' I I (A ii ) <br /> 9a. 9b. U.S. DOT Description (including Proper Shipping Name, Hazard Class, ID Number, 10. Containers 11 , Total 12, Unit <br /> HM and Packing Group (if any)) No. Type Quantity W(.NoI. <br /> � 1I11'Iifr-tii1 . lA�liVt= FttiAt 1lVAtifk- . Al_ RUtx'.)t_ :, . :.' I 1 { '?vt t 'itr i <br /> Z 21 <br /> LU . <br /> t.7 <br /> 3. <br /> d . <br /> r <br /> 13. Special Handling Instructions and Additional Information <br /> PttOFil L4 10104181 - 01 ) Af Fi� l t}t„ ; F Ftt �k 1 . ti <br /> } c.+ xvtA(, t . . t�. RECEIVED AUG 25 1020 <br /> 14, GENERATOR'S CERTIFICATION: I certify the materials described above on this manifest are not subject to federal regulations for reporting proper disposal of Hazardous Waste, <br /> Generators/Offerors PriniedlTyped Name Signature i Month Day Year <br /> —r 15. International Shipments <br /> F- ❑ Import to U.S. ❑ Export from U.S. Port of entrylexit: <br /> z Transporter signature (for exports only): Date leaving U.S.: <br /> U 16. Transporter Acknowledgment of Receipt of Materials <br /> Ej Transporter 1 Printed/Typed Name Signature f Month Day Year <br /> CL <br /> ZTransporter 2 Prinled(Typed Name Signature Month Day Year <br /> r- <br /> 17. Discrepancy <br /> 17a. Discrepancy Indication Space ❑ Quantity ❑ Type ❑ Residue ❑ Partial RejectionRejection <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 /> a (1 <br /> z <br /> 0 <br /> y , <br /> UJ <br /> 0 <br /> 18, Designated Facility Owner or Operator: Cedificalion of receipt of materials covered by the manifest except as noted in Item 17a <br /> Printed/Typed Name Signature Month Day Year <br /> 6-NHM-C-C-11 <br /> &GENERATOR'S INITIAL COPY <br />