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NOH-HAZARDOUS 1 l•Generator ID Number 2.Page 1 0l 3-Emergency Response Phone 4.Waste Tracking Number WASTE MANIFEST 1 5.Generator's Name and Mailing Address Generator's Site Address(if different than mailing address) Generator's Phone: �'7 -'T) L-7 7 6,Transporter l Company Name U.S.EPA ID Number 7.Transporter 2 Company Name U.S.FPA ID Number &Designated Fad IV Name and Site Address U-S-EPA ID Number f. L A'L "� c1q;t Fac Ii 's Phone: -4 7 9.Waste Shipping Name and Description 16.Containers 11-Total 12.Unit Na. Type Quantity WlNal- 1- O a � , w auj 2 [7 3- 4. 13-Special Handling Instructions and Additional Inlormation t �rlrrI7 0 A + PH L S - - -2 14.GENERATOR'S10FFEROR'S CERTIFICATION:I hereby declare thal the contents of this consignment are linty and a=ralely described above by the proper shipping name•and are ctasmrsed,packaged, marked and labeledlpfacarded,and are in all respects in proper condition for transport according to applicable international and national governmental regulations, GBneratDrslOfferors PrmtedlTyped Name Signature r Month Day Year r 15.Inlemabonal Shipments i` ❑Import 10 U.S. ❑Export from U.S- Port of enrrylexit: a Trans iter Signature Ifor exports only): Dale ieavin U.S.: rr 16.Transporter Acknowledgment of Receipt of Malepals Transpo BE 1 PrinledrTyped Name Si nature a -- Month Day Year co a Transporter 2 Pr ntedlfyped Name Signalure Month pay Year F 17.Discrepancy 17a-Discrepancy Indication Space ❑Quanfily ❑Type ❑Aesidue ❑Pam AeJection ❑Full Rejection Manifest Reference Number. 170.Aftemale Facility(or Generator) U.S-EPA ID Number J V Facility's Phone: 17c.S gnalure of Allemate Facility for Generator] a Month pay Year z 18-Designated Facrlrty Owner or Operator.Certification of receipt of malenalS Covered by the marutesl excaPI as Mad in Item 17a PdnfadlTyped Name Signature Month Day Year 169-BLC-45 11977[Rev.9109] GENERATOR'S/SHIPPER'S INITIAL COPY