Laserfiche WebLink
Please print or t e. (Form designed for use on elite 12 -pitch typewriter <br />NON•HAMWOUS 1. Generator 10 Numher <br />WASTE MANIFEST � -At (1 -113-A r 4 <br />5. Generate(-; Name and Melling Ad&-gs i. i..AldCa � i)P4 <br />S. Transpnner i compo,,y .a <br />4sklr:.* }IAit AWS '(')LUTIONS . )4#:: <br />7. Transporter 2 Company Name <br />(t. Designated Facility Name and Site Address 14i f;.!:iF1r>C, A. )...f• <br />1 t$ tflfl A't E fi?f X•t; Feil <br />I-actl6 s Phone: <br />9a 9b, U,S. DOT Description (including Propar Shipping Namv. Hazard Class, ID V r bar, <br />lint and Packing Group (if any)) — <br />1. 4 .1 C, 11;i <br />z 2 <br />w <br />t9 <br />f ONO <br />Page 1 of 3. t rnargencY rcnspui <br />1-0. CCoonntaalln�ersrs <br />No. I <br />. RECEIVED <br />A. Waste Tracking Number <br />OCT 18 2013 <br />than mailinq a(MENVIRONMENTAL <br />HEALTH DEPARTMENT <br />U S. EPA !U Number <br />AC 7 <br />lJ S. FPA 10 Number <br />�: �e�xl�tlRNl�3 9t�3 <br />11, Total 12. Unit <br />Quantity I WUvbl <br />1A. GENERATOR'S GERTfflCATION; I cetBfy ltM materials desarihed above nn this manifest are not subject W federal regulations to reporting propnr disposal of Nazardnus� Waste. <br />Signature <br />Ge(terator's10(feror's`Pdntedffyped NaMe <br />5, nternetional Shipments Export from U.S. <br />1Prat of entrylexih <br />❑ Import to U.S. Date Vaaving U.S.; <br />z Transporter signature (for exports only): <br />M 16. TranspoAe.r Admowledgnront of Receipt of Materials Signature d <br />aTransporter 1 Printg�llTYPed Name <br />Q1 r'� p <br />r Signature <br />Transponer 2 Printed Name <br />t - <br />1'l. Discrepenry ❑ .jype Partial Refection <br />I-� 0❑Residue <br />178. Discrepancy Indication space D Quantity <br />Manifest Reference Number: 11.3. EPA in Number T <br />17h. Alternate para1Ny (or Generator) <br />FacAllY's Phone: <br />U, 17r.. Signature ofAltntnate, Facility (or Generator) <br />CIP <br />W <br />10 <br />1 B. Designated Pacikly Owner nr Operator. Cerdfiratlrm of receipt of materials covered by iho —d`t except as noted in Item 17a <br />Signrdre <br />PrintedlTyped Name I --- <br />Year.., <br />Year <br />0 Full Rejection <br />C._9,l=PrFRn'Tnr1`r= rhrr'Irf P i rr14? <br />