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Li] <br />t <br />I' <br />,.. <br />i•-ct re w z w ta <br />ZI-4 <br />S' <br />...* <br />-4 ... <br />NON-HAZARDOUS <br />WASTE MANIFEST <br />1. Generator ID Islumber <br />. <br />. <br />2. Page I of 3. Emergency Response l'hono 4. Waste Tracking bar <br />5, Generator's Kime and Wittig Address Generator% Spa AddresS(ildiffriteni than tnailing.riddi OS 5) _ <br />Generator's Phone: I <br />2.i., <br />Transporter 1CompanY blime ' ' U.S. EPA ID Number <br />, ... I .4. Tranapartar 2 C;nmpany t"RnIF: U.S. EPA ID Number <br />1 - <br />roo, <br />... <br />tr,t 6. Designated Facility Name and Site Address U.S. EPATD Number <br />1 • , <br />. . . . .. <br />FanTly's Phone: r 1 i ,:. <br />,51 <br />i., <br />9. Waste Shipping Name and Desambor, ta avniainfirs II. Total 12. Unit <br />.. .... <br />No. rY94 Quantity 17/11Vol. ev. <br />- 1 <br />- — • <br />r <br />to <br />.1. <br />e <br />I; <br />' <br />13. Special Handling Instuclons and Adgkional Inbrmation <br />.. <br />.- <br />L <br />14. GENERATORS/OFFERORS CERTIFICATION: I hereby declare that the contents ol this consignment are fully and accurately described above by the proper thipping name, and are classified, packaged, <br />marked god iaboledIplacarded. and are m all trspatis in proper condton tor transport according lo arOcabie International and r.ational governmental regulations. <br />Generator's/Offeror-5 PrIntorliTyped Name Signature Month Day Year <br />.. • • k <br />I I I I , <br />fr !VVIRMiTeRarZEgeXg TRANSPORTER INT'L 15. Ihlemationdi Shipments tarpon to U.S. 0 Export Item U.S Port ol entrylaxit: <br />, <br />Transporter Signature (tot exports only): Data leaving U,S.: <br />16. Transporter Acknowledgment of Receipt ol Materials <br />A Transporter 1.prinled/Typed Name Signature Month Day Year <br />Transperter 2 Printed/Typed Name Signature Month Day Year <br />I I I i <br />' <br />ril .7%crApziPre'415N-44MAN.,474001KTEMPIRMKtafai*IP DESIGNATED FACILITY 17. Diserepancy <br />170 Discrepancy Indication Space <br />Oultniity CI Type Residua Partial Rejection <br />Manilas' !Inference Number: <br />111 Full Rejection '214 <br />Alternate Facility (or Gonerator) U.S. EPA 11) Number <br />Facility's Phone: I <br />sArs 1,• <br />fri' rica <br />Signature of Alternate Facility (or Generator) Month Day Year <br />I L I _I r <br />rA 4, <br />IAA <br />.m4 Titl, <br />at <br />18. Designated Facility Queer or Operator Certification ol mealpt ol materials covered by the manifest except as noted in Hem 17a <br />Printed/Typed Name Signature Month Day Year <br />169-BLC-0 6 10498 (Rev. 9/09) GENERATOR'S/SHIPPER'S INITIAL COPY