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<br />NON•HAZARDOUS
<br />WASTE MANIFEST
<br />1- General°' ID Nurriboi
<br />4. ' A- i , 71? i ;I: t Itr.; ' .: • '
<br />2. Page 1 of 3. Emergency Response Phone
<br />;7•7,7,2!1 •11 :;•••:.".• ;,r'ttel,10Q.:i,
<br />4. Waste Tracking Number
<br />i Generator's Name and Mailing Address
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<br />144',•Ft;2.:,3$1. 4:',i7 'P •:::.7. ,..,,
<br />Generator's Phone:
<br />Generator's Site Address (It different than mallir,g address) '
<br />Transporter 1 Company' Nairie
<br />i: '..:, 1.-,,i;•.:' ...42...:M'ii",'.1..e•ki'''. '7.KY",,‘1:1..i.:1
<br />U.S. EPA 10 Neater
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<br />Transporter 2 Conipany Name U.S. EPA ID Number
<br />Designated Facility Name and Site Address U.S. EPA ID Number
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<br />Facility's Phone: 'iPI.. '4a..,31---f.'..i.fs::.f.Y. p; 1
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<br />Waste Snipping No and Description me Contaifiers Total Unit
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<br />No Type Cuaribly WI.Nol.
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<br />771 cc u:
<br />f. ?Ifir-1-141.:':"'Atf. . .i.eato, (i.-44.m. (0 i °:11.,,:e.1` ..''i
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<br />1. S eclat Handling Inptructioos and Additional inionnaiOn
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<br />4.404 /71:-..• '
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<br />14. GENERATOR'S/OFFESOR'S CERTIFICATION; I hereby declare that the contents of this consignment are Idly and accurately described above by the proper shipping name, and are classified, packaged,
<br />Marked and iabetediplicarded, and gm in all to poets in proper contlion for transport according to applicable International and national govemmeatalmetations. ii...
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<br />GenereforsiCifferorerrintedayped Name Signature, . ,'' ) 4.1,1C .' ,,,.., Yo# 1 ,, / .........— u e. !.., i. ,._, .... 4-c., . 4,1 ,,,.• e AL .
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<br />IS International Shipments CI Import to U.S. ....t • .. .
<br />III Export from U.S. Port of entry/ox r , Transporter Signature (Ion exports only): Date leaving U.S.: . SS=ICElt: TRANSPORTER 16. Transporter Acknowledgment of Receipt of Materials
<br />Transporter I PrintedgyperiName Signature 1,Appfi •
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<br />... Transporter 2 Printed/Typed Name Signature
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<br />Year - • DESIGNATED FACILITY i 17, Dixreoancv , ri3
<br />via. Discrepancy indication Space
<br />Quantify IIII
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<br />Type 0 Residua Li Partial Rejection
<br />Manifest Relerence Number:
<br />U Full Refection .
<br />I 7b. Alternate Facility (or Generator) U.S. EPA ID Number
<br />Facility's Phone:
<br />17c. Signature of Alternate Feat? (or Generator) 7.1onlh Day Year
<br />I I N'
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<br />IS. Designated Facility Owner or Operator. Certlfication of receipt of materials covered by the manifest except as haled in heir 17a
<br />' Printed/Typed Name Signature Month Day . Year
<br />169-13LC-0 6 10498 (Rev. 9109) TRANSPORTER #1
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