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<br />NONHAZARDOUS
<br />WASTE MANIFEST
<br />I. Gelithlar ID Nualber
<br />11:,,-A4,,.• 40 5 ) 0.0164
<br />2. Page 1 of 3. Emorgonoi n06[101),S0 P110110
<br />ki 77 -,n,,(,..-.1065
<br />4. Wosio Tracking Number
<br />..2-2.,,211024. VI 7 Generates Name and Mailing Address . Generalor's Site Address pi different than mailing address) ;,,-:, pt4..w,;t1
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<br />Generator's Phone: 45.4,1-VIVAI
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<br />45
<br />Transporter 1 Company Name U.S. EPA ID Mother
<br />rtilltia. bihrtrAfttlaciftit $64Wit,.tln ,.', IA:. g iitt)i) $ Itii 0 x a i
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<br />7, Transporter 2 Company Name , U.S. EPA ID Number
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<br />Facit-re's
<br />8. Dosignaled Facility yarns and Silo Address U.S. EPA ID Neater '1 tOtOOK.
<br />I i 0.54.: A4pOIT ftfri
<br />?MO Vt.'44k 4...4 44'Vt
<br />Phone: '':,40-tii,!.g V:,1,1? I f'4 1 114
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<br />9. Waste Shipping Name and Desciption 10. Containers 11. Total 12. Unit
<br />No. Type Quantity VitiVol, :r.
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<br />. PMV.-#teatiArifEtA5 W -41* ilkfiAli 111:0 S
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<br />Speciagolawdfin, Inajmiccgia end/Additional\ Informyr
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<br />GENERATORWOFFEROR'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, pada*,
<br />rna.rked and labuled/placarded, end are In all respects in propercerefition for If8119pOrt according to applicable International and national governmental regulations.
<br />Generator's/Offerors Printed/Typed Name Signature Month Day; Year
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<br />International Shipments El Import to U.S. III Export from U.S. Pondl entry/exit'
<br />Trans,. tier %nature !for exports oaf , : Dale leaving U.S.: TRANSPORTER IS. Transporter Acknowledgment of Receipt of Materials
<br />Transporter 1 Printed/TypedName Signature Meath DO Year
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<br />Transporter 2 Printed/Typed Name Signature Month DaY Year
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<br />ill 4.,t4WAWMXIMAtairgPtINAVA DESIGNATED. FACILITY .. • . • f Discrepancy 1: 17a. Discrepancy Indication Space 10 Quantity 0 Type 0 Redden Partial Rejection 0Full Rejection
<br />Manifest Reference Number. :of
<br />17b, Alternate Facility (er Generator) U.S. EPA 10 Minter
<br />Facility's Phone:
<br />17c. Signature of Alternate Fealty for Generator) Moth Day Year
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<br />Designated Fealty °valet or Operator: Certification of receipt cl materials covered by the manifest except as noted in Item 17a v. 1 PentedTyped Name Signature Month Day, Year '
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<br />169-EILC-0 6 10496 (Rev. 9/09)
<br />TRANSPORTER #1
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