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<br />NON-HAZARDOUS
<br />WASTE MANIFEST
<br />I. Generator ID Number
<br />(14:1141131k.'..-i,
<br />2. Page 1 of
<br />4
<br />3 Emergency Response Phone f 4, Waste Tracking Number
<br />,T:.;r-.7 ,.-,!4r,,E;',s'. ! 22.,..2604."';' .0) 9
<br />4
<br />, Generator's Name and Meng Address Generato(s She Address' (if different than mailing address) 4 . 5Y:U135er, fliiig1i2rf) Witt; 1)/trile°5_41
<br />'' tkka•4fk. iArifiri7.04 1".7: .. 1'
<br />Generator's Phone: NS' .. v_.sns uca
<br />Transporter 1 Company Name U.S. EPA ID Number rP
<br />ARP,* id feilMillfirttA :i.Unfitaise I IL.Ail 000 ,/ :0 7, Transporter 2 CoMpany Name U.S. EPAID Ndmber '
<br />I
<br />Facilil
<br />8. Designated Facility Nnine and She Address U.S. EPA ID Ntualm
<br />htetftt IfIC
<br />1 i0t4.7.100.pthit.CLi .
<br />RIO klUtik, fAIN5 ri ..,,,
<br />s Phone. 134,21._41-3$10.9 AA i a e,,
<br />O. Waste Shipping Name and Description la Containers 11. Total 12, Unit A i p
<br />No. Type Quantity W1Noi,
<br />' air .-4.3 %IVA .
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<br />II
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<br />Spetiel Handling Instructions ar!d•Additional Intonation
<br />1 1 P.T.4101, V, I... ' . i.. ' ; ''', k•-kt
<br />70'--
<br />4.,
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<br />GENERATOR•S/OFFERORS CERTIFICATION: I hereby de,clare that the contents at this consignment are forty and accurately described above by the proper shipping name: and are classIged, packaged, *--
<br />marked and labeletplacarded, and arekt all respects in proper condition for transport according to applObie international and national governmental regulations. ;
<br />.1
<br />Generator'sZileroes PrintediTyped Name Signature ,
<br />
<br />. i ,... ,a, r rf , A : .. 1 s ' h :(1. i) ili a . ' ; ..i. ' t- i A .' f , •
<br />Month Day Year V
<br />1;. i 14 t ...) ' I . I :sik C. ,,..1
<br />—
<br />15. Info:national Shipments
<br />Import to U.S. &pod from U.S. Port of entrylexit
<br />Trans "der Si'nature (for evens only): Date leaving U.S.:
<br />vi TRANSPORTER 16. Transporter Acknowledgment of Receipt of kiatedats
<br />Transporter 1 rInted/Typed Name Signature Month Day Year '
<br />A.F _
<br />: , ri c.4•11i: X,. .k,../"..- r i.i ./),Ii b
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<br />Tragporler 2 PrintedfTyped'Hame ' Sigriattle ' • Minh Day Veal' 1.•
<br />I I. J I tigovrit w'IMiraRM 17. Discrepancy - -
<br />Discrepancy Indication Space r_J i . L Quanhly Type
<br />tAantlest
<br />:
<br />III Residue 0 Partial Rejection 0Full Rejection
<br />Reference Number z..
<br />Alternate Facility (or Generator) U.S. EPA ID Number .r4
<br />Faalky's Phone: I
<br />I7c. Signature of Alternate Facility (cc Generator) month Day Year p.
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<br />. i •,_.,‘ . A •
<br />18. Designated Facility Owner or OPeraior. Certification of receipt of materials covered by the manliest except a.s noted In Item 17a .
<br />PrIntedfiyped Name fA Signature , ._ , Month Day r • ! e -
<br />1 (' ) t./ i V ,r:, •1_,,..• i-t r" 1 3 - . y F.'
<br />169-13LC-0 6 10496 (Rev. 9/09) TRANSPORTER #1
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