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; NON-HAZARDOUS <br />I WASTE MAMIFEST <br />1. Generator ID Number 2. Page 1 of 3. Emergency Response Phone 4. Waste Tracking Number <br />i 5 '1;:ifFfOr'S Name and Mailing Address Generator's Site Address (if different than mailing address) <br />70: - .. <br />Or. ..; , .. <br />. ,larlapolts IN 4827$i <br />_ <br />z-•?nor, <br />Generators Phone: - ,.; r. ------ <br /> <br />3. Transporter 1 Company Name U.S. EPA ID Number <br />i <br />i <br />____F_Z .- O", "::.- • - -- ,• E : ..-, -- ...t ' - '-' -• 7, '. <br />, 7. Transporter 2 Company Name U.S. EPA ID Number <br />i 3. CeAignatee cnnility Name- and Site Address U.S. EPA ID Number <br /> <br />... :76 : r-414.1.11flf <br /> <br />St.itS'-7 C.i'. ::.A 04581. <br />Fad 's P!-one: 7 • 4:,;,; yi.x. C -.. .:: -• 1.' ' n 3 .; ' , <br />10. Containers 11. Total 12. Unit <br />, .9. Waste Shipping Name and Description No. Type Quantity W1A/o1. <br />C, <br />ti <br />Lc <br />iu <br />';1.AL-, ';.7.t':.',..iC: <br />:-r ,-,':,T L,:'..:: E ,...):•_.- 60l. 15 <br />..., z 0 <br />, <br />13. Speciel <br />' Plt- <br />, <br />' <br />wRzeee <br />Handfing Instructions and Additional Information <br /> <br /> <br />.r-St P 13 a-i 4/4-- TA g 5 yeDS Jit 11-20 -Q06SO <br />PMLF -Z1 -Oit <br />.. . Ir-v_ <br /> <br />1 14. GENISIOteni <br />, .0.-....iaviii ...iiiiii44 • -- - • '- l'• -4-7'1- • - -- <br />FERO S ERTI ATION: 1 hereby declare that the contents oi this Ccr:s.y:r.: ap) : r --: -. i :-.... i.i. i abase by he proper snipping name, and are classified, packaged, <br /> <br />markeu tift:i labeled/placarded. and are in all respects in proper condition for transport according to a fe : al vemmental regulations. <br />i Generator's/Offerors Printed/Typed Name S Month <br />2- <br />Day <br />2.-'2--\ <br />Year <br />... ..5. 'n'eTationa. Snipments D III Export r Import to U.S. <br />Z i — Transporter S nWLa y)i arts onl : Oar... i <br />1 . rr i 10. Transporter Acknowledgment of Receipt I of Materials <br />Lil 1 L 1 Transporter 1 Printed/Typed Name Signatur Month Day Year <br />S.) I LIF E 3E 4,;: -.. _ ‘.. - -L- '-"Z) <br />! Tranic::-te! 2 Printed•Typed Name Signature Month Day <br />a • <br />1-- : I I <br />i I 17. Discrepancy <br />T t. 17a. Discrepancy Indication Space El Quantity El Type Residue Partial Rejection E Full Rejection <br />i <br />I Manifest Reference Number r !, 17b. Alternate Facility (or Generator) U.S.EPA ID Number <br />Z.3 . a , . i-adlily'e Phone: <br />a I" .., tu , : . c Signature of Alternate Facility (or Generator) Month Day Year <br />r . 4 ' <br />a <br />0 <br />aj Ira' <br />18. Designated Facility Owner Of Operator. Certification of receipt of matenais covered by the manifest except as noted in Item 17a <br />: PrintecVTyped Name ji <br />...5z......_,... 1 Signature Month Day Year <br />1 <br /> <br />La- ,;(1 ATEll rArit ITV TC1 (IFNFRATC)11 no_cti a -mama 112au Wital