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<br />' C C n 111
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<br />NONHAZARDOUS
<br />WASTE MANIFEST
<br />I. Generator 10 Number
<br />ft,7ACC:7'F'.,1 St': .-1.!,•••.` ':ci ,
<br />2. Page I of
<br />1 ,
<br />3 Emergency Response Phone
<br />WP 7. 2R-L-4'`.*•::',:,;
<br />4. Waste TrackingNember
<br />22, )4)n .A141'1 S. Generator's Name and Mailing Addres. , . .._ , , Generator's SRO Address (if different than mailing address) rigit Lscl Itergr *SESLI71.:5)7.... iiiia4:,..‘fk, Lk': orsp
<br />914.0*V1 CA V54,:iii.-
<br />Generator's Phone: 2V/1,14M 'PA I
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<br />6 Transpolar 1 Company Name — ' • US. EPA ID Number
<br />ftmgdfor titrittotatidit .*,14604..1 1 CAfit).01) A 40 Al
<br />7. Transporter 2 Company Name U.S. EPA 10 Winter
<br />•
<br />S. Designated Fac.ftV Name and Site Address U.S. EPA ID Number
<br />bre,4004 fhC
<br />i f D51...; Afrpo itki
<br />fdt. V110.P. CA 14%.7,1
<br />Facility's Phone: 1 4.-ElaVItI CO rii i'" A ? ,..,,
<br />2, Waste Shipping Name and Description to. Containers II. Total 12. Unit
<br /> .thwgi Ncigr,p6m„iiw;-,-i.,-..-„,,,, 0.,.91,q ,
<br />No. Type Quantity WI/Vol. 1
<br />tc :,........ ..1 1
<br />C . / 1
<br />i. . .:. ••". 3. ,
<br />If '5.00
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<br />13 speci nkg Inslikl;t1ops'and Idditional,inf$1thatipn,,c%
<br />MIti, '114440
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<br />GENERATOR'S/OFFERORS CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by the proper shipping name; and are classified, packaged,
<br />marked and labeled0Carded, andere in an respects in proper condition for transport accordingto applicable international and national gcnremtental regulations. Pk1 Generator's/Offenses Printed/Typed Narte ! \ Signature , r4. ot Month - ' '. / i , ' ! „..., _-
<br />1 A / /11, r; l lrb i i" r .1., ! t:, li • .;.', 'I , ?If.; . ' .. i il ,\„/ ,1 I I:1 'x' . .
<br />Day
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<br />Year
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<br />4
<br />International Shipments III Import to U.S. il Export from U.S. Pod of entry/oil-
<br />Transporter Signature flee exports only): Date lea*, US.: WW4751itiii". TRANSPORTER 18, Transporter Acknowledgment of Receipt ol Materials .,
<br />Trandtrolber 1 PrIntedri}rped Name Signature Month Day Year
<br />I ftkt'litod i ss,c'. rt,..T,A.1 I ' ' - '...
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<br />Transporter 2 PrintetIrTyped Name AR. • Sigifitilm anti' Day Year
<br />I,.. DESIGNATED FACILITY Discrepancy rs
<br />tie. Discrepancy Indication Space
<br />iii Type Fiesidua Partial Rejection Pull ReiKtion
<br />Manifest Ratan:me Number:
<br />17b. Alternate Facility (or Generator) U.S. EPA ID Number
<br />Facility's Phone: 1 In : I7c, Signature of Alternate Facility (or Gen Dreier) Month Day Year
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<br />NA' 1,141.11
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<br />Designated Facility Owner or Operator: Cortifcation ol receipt of materials covered by the manifest except as noted in Item 17a ra
<br />PrintecirTyped Name Signature Month Day Year
<br />• I I '.. ;.- `I'' I .:•".
<br />169-BLC-0 6 10498 (Rev. 9/09)
<br />TRANSPORTER #1
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