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<br />NON-HAZARDOUS
<br />WASTE MANIFEST
<br />I. Generator ID tl.trnbar, : 2. Page 1 el
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<br />a Emergency Repcnse Phone _
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<br />It Waste Tratking_Number
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<br />Generator's Name artdf,tailing Ad eon , . , Generator's Site Address (it different than mating address) . t . .:,',' '..1...,..J.4.; ...• ft.,.., , ' '.'"•tii•al!Ottii . t,•'•• ••..;',. ,-1' :.'.'.••• •• :I..' . ''' '..
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<br />Generator's Ptorm: .,!T::,''':', ''.i• ',( 1.'4.10 I
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<br />, _ Transpcder I Company Name U.S. EPA ID Nuirther it. jirtitv: t. t 41,....‘,4";• f., A 4, f.t. 413. f,)
<br />Transporter 2 Company Name 115. EPA 10 Number
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<br />Factlit
<br />Designated EtçiIity Name and Site Address U.S. EPA1D Number
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<br />S. Waste Shipping Name and Description in. Containers it Total 12. Une
<br />No. Type Quantity WINO '...; i -*Tr*,,, '.6i#L i. ,,, Iv ,,,,?0,07,,,,,. 71..4. ., tk P
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<br />smio.pAptlipip Instructions and Additional infprmatiop,,,.. „ •
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<br />q.64.! ,11?..,;!;4:!,,,,,•.,"'
<br />GENERATOR'S/OFFEFIOR'S CERTIFICATION: I hereby de.clam that the contents alibis consignment are fully and accurately described above by tire proper shippinj name, and are classified, packaged,
<br />marked and labeled/placarded, and are in all respects In proper condition for transport according to applicable international and national governmental regUletiOns.
<br />Genoraloes/OfiferorarrintedrIfypeil Name
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<br />Signature /
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<br />IS. Shipments 0 Impart to U.S. 0 Export from U.S. Port ol anlryfexit 1 r Transporter Signature ger exports onlyi: Date teaving U.S.: 4 TRANSPORTER 16. Tratitnarter Acknowledgment of Receipt of Materials
<br />Transporter I PrintedrTyped Name, Signature ,., Pita411 , oo... Year ....' ..r. ,••
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<br />. Transporter 2 Printed/Typed Name Signature
<br />I Month Day Year - .
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<br />: - DESMNATED FACILITY I I 17. Discrepancy
<br />I7a. Discrepancy indication Space
<br />Quantity 0 Typ.r.,, Residua El Partial Rejection 0 Full Rejection
<br />Manifest Reference Number:
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<br />Alternate Peaty (or Generator) U.S. EPA ID Number
<br />Facility's Phone:
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<br />Signature of Alternate Facflity (or Generator) Month Day Year
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<br />18. Designated Facility Owner or Operator. Certification of receipt at materials covered by the manifest except as noted in Horn 17a .
<br />PrintedrTyped Name ; Signature Month Day .Ygar
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<br />169-BLC-0 6 10498 (Rev. 9/09) TRANSPORTER #1
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