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NON-HAZARDOUS 1.Generator ID NumberP.Page 1 of 3.Emergency Response Phone 4.Waste Tracking Number <br /> WASTE MANIFEST a .k <br /> 5.Generator's Name and Mailing Address Generaw,Site Address{if d lferer t than mailing add es <br /> s <br /> RTI: LHUFtL-fd f�.lf'ia rr-� <br /> OLD W iii:110N 7r[r—IG,'IT LIi�`;=ITX. OLD D�:iWtt0 1,1 f oliriMG;;T t-1iNt 1;''Z <br /> av OLD Z�31MIii:iGiti*X1 i,G i tDARGY FAA%TrVR( <br /> — r. . . <br /> 'IVlnne_,.-ir_ 1:L. i 3�0 inti i 11ROP CA 953:Z <br /> Generator's Phone: <br /> 6-Transporter 1 Company Ninie U.S.EPA ID Number <br /> 7.Transporter 2 Company Name U.S-EPA 1 umber - <br /> 8.Designated Facility Name and Site Address U.S-EPA 1D Number <br /> �'ttluu &V JtfY I L)N <br /> ita; VVLCi1 7!iF1:5IKLLI <br /> LU:,.t,a t5ttk(-;H i,H `..►W I,i <br /> Fadli 's Phone: F,2,- - <br /> � r <br /> S.Waste Shipping Name and Description <br /> 7o.Containers 11.Tolaf 12.Unit <br /> No. Type Quantity Wtivol. <br /> 1. <br /> g i'.i1rd HiV-Ait1-JQU .VVA�>I L t;ULIU-FUUU S I Uri- t <br /> a 4 <br /> LUL <br /> z 2. <br /> Lu <br /> f4lJi 1 1 NHUUJt,VJ=l'':,'I Iw Lii.UIU-i(JL1U'S I Urt- <br /> 3. <br /> 4. <br /> 13,Special Handling Instructions and.Addifional Information <br /> 0%-L, 4 h -a <br /> (A14 5� <br /> 14.GENERATOR'SIOFFEROR'S CERTIFICATION:I hereby dedare that the conlents of ddscdhed.ibbre byibe' t*Wft0azheihW am classified,packaged, <br /> _ marked and labeled,'placarded,and are in at respects in proper condition for transport according to applicable international and national governmental regulations. <br /> Generator s Offerors Printed/Typed Name 1. Signature Month Day Year <br /> a 15.1 ntemational Shipmenls L]Im r1 to U-S. ❑ 1 ! <br /> Z pa F_xport lrom U-S. Port of entrylexit: <br /> TraLsNrter Signature for exports onl : Date leaving U.S.: <br /> ¢ 16.Transporter Acknowledgment of Receipt of Materials <br /> uI <br /> Transporter 1 Printed/Typed Name ` i S gnature Mpnth Day Year <br /> �-4 L i �- <br /> z Transporter 2 PrintedTyped Name Signature Month Day Year <br /> i 1 <br /> 1- <br /> 17.Discrepancy <br /> 17a-Discrepancy Indication Space ❑Quantity ❑Type ❑Residue ❑Partial Rejection ❑Full Reject un <br /> Manifest Reference Number. <br /> 176.Alternate Facility(or Generator) U.S.EPA 10 Number <br /> 1 <br /> U <br /> LL Factity's Phone: <br /> 17c-Signature of Affemale Facility(or Generator) Month Day Year <br /> a <br /> z <br /> t0 <br /> w <br /> us <br /> 1S-Designated Facility Owner or Operator.Certification of receipt of maleriats covered by the manitest except as noted in Ilem 17a <br /> PrintedfTyped Name Signature Month Day Year <br /> 169-Bt_C-0 5 11977(Rev.9109) GENERATOR'S/SHIPPER'S INITIAL COPY <br />