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NON-HAZARDOUS 1.Generator ID Number 2.Page 1 of 3.Emliguncy,Response Phon° 4.Waste TragAing Nu�nbcrr y�J ✓ <br /> WASTE MANIFEST GAL�3�D 131185 i 7 f�- <br /> .!a1I.gqSddtess Generator's Sili Address(it dilfarent than mai ng address) <br /> t?5190 l`.d7fin Or ?�"3�`iCl�sd R O i.•:' <br /> ' '(801)rZFrr-:ae!•}ii i.iiiafiui �g,�i�-�,x 3:53: z <br /> Generator's Phcno: <br /> 6.Transporter 1 Company Name U.S.EPA ID Number <br /> i ',reU.Jf'ni.°i!t./Irl?:url�i?�a�,..�5-.ticr•,.� l.e+.• I ("AxiV91)1c>rr.v: <br /> 7.T ransparter 2 Company Mame U.S.EPA ID I•lumber <br /> 6.Dad 9,P cd•�a Iamc-and Site Address U.S.EPA ID Number r <br /> nr.w:rc,. rAV :34 <br /> Factit's Prone: <br /> 10.Con ta;ners 11.Tola1 12.Uril <br /> 9.ylasle Shipping Name and Description <br /> F:a. Type Ouanaty 17t�\cl. <br /> 1 Ii`ia.i•a i:i ;lbi":nrl,a tISJ,7. ��. ;1. �.. 1 ` /7` r�Cti r — <br /> 0 �.i :� i:••% c] 3:� 4�7 S ii:i:i..tv! t :-1' l `lv <br /> Q _ . <br /> W - <br /> Z 2. <br /> W <br /> G7 <br /> 3. <br /> 4. <br /> 13.SpcciJ Handing Instructions and Additional Information <br /> r . <br /> 14.GENERATOR'S/OFFEROR'S CERTIFICATION:I hereby deciare that the contents of this censignmanl are fully and accurately d3sait;ed above by the proper shipping name,arA are ciassi`cd.packaged, <br /> marked and labelecVpiacarded,and are in all respects in proper condlion for transport according to applicable international and national go <br /> �emmenlal regulations. <br /> Generalor'JOlferces PrintedRyp=d Name S:gnalure_ Month Day Yea; <br /> J 15.IntarnaGcnaIShpmenls <br /> ❑Import to U.S. ❑Export 1.U.S. Pad of entry/axil: <br /> Trans at•:r Siana:ure(for exports only): Date leaving U.S.: <br /> ¢ 16.Transpceor A6nov:'•:dgrrenl of Receipt o`Rtaleriais <br /> F_ Tran>pgrtcr,t Qrinled,7yped P ame 1 Signature ticnih Da�:'' � y Year <br /> QTranspmler 2 Prinle%rryped Name Signature- Daorilh Day Yea• <br /> 17.Discrepancy <br /> 17a.Discrcparcy Ind:caton Space <br /> ❑Guanlily ❑Type El Residue ❑Partial P.eecticn LJ Full Rejec:icn <br /> Marofest Reference Plumber: <br /> Y 17b.Aaem=_te Facliry(or Gere:alcr) U.S.EPA ID Plumder <br /> J <br /> V i <br /> tai Facil,,s Fhcne: <br /> 0 17c.Stgnalum of Nlernale Facility(or Generator) t.irclh Day Ycar <br /> Z <br /> -1-- -�-- <br /> 113.Designated Facit:ly Cviner or Operator;Cedificilion of receipl of materials covered by the manifest except as rcled in Item 17a + _ <br /> PrintedRypedPlama r r., -- Signature %, ; j' -----Iarnth D,;y Year <br /> 159-BLC-0 5 11977(Rev.9/09) I TRANSPORTF_I. ;'1 <br /> � D� 7 � <br />