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NON-HAZARDOUS 1��•11Generalpor IDpNam ber 2.Page 1 of 3.Emerggency Response Phone 7 4.Waste Tracking LA-T- <br /> r � a, <br /> WASTE MANIFEST �J �v� � �' OriQr7� TI .J QP FC— L A—T— N O V I <br /> 5.Generator's Name and Mailing Address Generator's Site Address(if different than mailing address) 4, <br /> 01-7) D°M � n 10 N C tG 1' T LJ IVE i <br /> C7 6Lr7nt�;- <br /> Ait <br /> Generators Phone. <br /> 6.Transpoiter 1 Company i U. EPA ID Number <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> 8.Designated Facility ame and Site Address U.S.EPA 10 Number' <br /> AJ 0 <br /> Facilit's Phone: 3 <br /> 10.Containers 11.Total 12.Unit <br /> 9.Waste Shipping Name and Description ° <br /> No. Type Quantity Wt.Nol. <br /> 1- NVil f kUrP-0 r, IQwr 1C01-P Q <br /> LLI <br /> 2. <br /> L - } <br /> 3 <br /> 3. 7 <br /> F\G <br /> 4. <br /> f <br /> 13.Special Handling Instructions and Additional Information ` r <br /> 14.GENERATORVOFFEll CERTIFICATION:€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 for transport according to applicable international and national godgrnmental regulations. <br /> Gener r's/Olfercr's PrilledlTy ed Name Sign tore Month Da Year e <br /> LQw6l <br /> _J 15.In ernationalhipm its <br /> ❑Import to U.S. ❑Expert from .S, o nlrylexit: <br /> z <br /> Transporter Signature f r exports only): eavin U.S.: <br /> ce 16.Transporter Ackno dgment of Receipt of MaterialsLu r ' <br /> r ¢ Transported Pri petl Name r Signature Month Day Year <br /> a a �� <br /> a Transporter 2 Printedffype Name Signature Month Day Year <br /> 17.Discrepancy „1 <br /> 17a.Discrepancy Indication Space ae <br /> ❑quantity El Type ❑Residue ❑Partial Rejection ❑Full Rejection <br /> u; <br /> Manifest Reference Number: ' <br /> r } 17b.Alternate Facility(or Generator) 7 EFF T U.S.EPA ID Number <br /> r.. <br /> Ne' u_ Facility's Phone: kms. <br /> LU <br /> 17c.Signature of Alternate Facility(or Generator) " _ Month Day Year br <br /> h"s 4L;, <br /> w <br /> Lu J u3 ]q <br /> 18.Designated Facility Owner or 0 erator:Certification of receipt of materials covered by the manifest except as noted in Item"a <br /> r � Printedfi'yped Signatu Month Day Year <br /> :r <br /> 169-BLC-0 5.14477(Rev.9109) DESIGNATED FACILITY TO GENERATOR <br />