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Cr3 <br />fa, <br />0.1 <br />1 I . . . _ INT'L I 4 GENERATOR NON-HAZARDOUS <br />WASTE MANIFEST <br />1. Generator ID Number <br />r-s,t-vm-C <br />2. Page 1 of <br />I <br />3. Emergency Response Phone <br />*CC: • 5•1. •iL_ir <br />4. Waste Tracking Number <br />Iii.G- t Ci t 1.4:',17)., <br />Generator's Name and Mating Address Generator's Site Address (II different than mailing address) AvcA.4., Z.11 ittn,c <br />.p..I.A Dt4. wtti; c.:ciaaret cv Aitco itiAin) t• e-co.-svic4 0;tuiv <br />L.,,x ,_1 c4 I bticeizte,.\ e4 1,1..x.t.,5 <br />Generator's f'bone. <br />Transporter 1 Company Name U.S. EPA ID Number <br />7, Transporter 2 Company Name U.S. EPA ID Number <br />I <br />11:)S <br />sliejW <br />Facility'A <br />8. Designated <br />cttIlx-e, <br />Facility Name and Site Address <br />iivi.4--s toimix tu.L. <br />kareile ituAs li.vc <br /> <br />. CA IH -.6 <br /> <br />Phone: .1.4 • ATI- litig <br />U.S. EPA ID Number <br />9. Waste Shipping Name and Description 10. Containers 11. Total 12. Unit <br />No. Type Quantity Wt.Nol. <br />1 144.,•,-, iukzAi-l.c3::,i-j. '..All'i•L <br />Ot i cc )700 Ei <br />2 <br />3 <br />4. <br />Special HandlingJnstructions and Additional Information <br />likiti..441. PQ,cyl.ast VOL. 444.ego tkAikai-wc <br />Hir , II . '1*0371- <br />0101711.-V t Mk 1-V - "i; • OS <br />GENERATOR'S/OFFEROR'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, package <br />marked and labeled/placarded, and are in all respects in proper condition for transport according to applicable international and national governmental regulations. <br />Generators/Offeror's Printed/Typed Name Signature Month Day <br />Fric PcircIo r) 5 , I er I NI I '5. International Shipments LII Import to U.S. Export from Port of entry/exit <br />Transporter Signature (for exports only): Date leaving U.S.: <br />m <br />E <br />; 4 <br />I 16. Transporter Acknowledgment of Receipt of Materials <br />Transporter 1 Printed/Typed Name Si gnre <br />1•-•''' <br />Month Day <br />— ' <br />Transporter 2 Printed/Typed Na I Signa e 1 Month Day <br />I I z.• DESIGNATED FACILITY t 17. Discrepancy <br />17a, Discrepancy Indication Space <br />Quantity Type Li Residue Li Partial Rejection Full Rejectic <br />Manifest Reference Number: <br />Alternate Facility (or Generator) U.S. EPA ID Number <br />Facility's Phone: 1 <br />Signature of Alternate Facility (or Generator) Month Day <br />I I I I <br />18. Designated Facility Owner or Operator. Co eceipt of materials covered by the manifest except as noted in Item 17a 1111 <br />Printed/Typed Name Signature <br />I <br />rth <br />e‘ <br />169-BLC-0 5 11977 (Rev. 9/09) <br />DESIGNATED FACILITY 'M GL'INsIERi