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t�,o►,.PAN a Jypy <br /> NON-HAZARDOUS 1 Generator ID Nrmbe 2,Page 1 of 3.Emergency Response Phone -L 4.Waste Tracking Number <br /> WASTE MANIFEST t �gg 'g �-'7 2-6 4 <br /> -_- <br /> 5.Gen a s Na a an�+aiL p�dr Generaloes Slte Addr 1 tha�paic�r,�aridness <br /> n 1'a►t� iC. ilr'oa� ��a �rt� t/ltnia►t rau"1���- lcolr ✓oca� <br /> bSZd /�tra -'(a•et,J 1Odo C f2-.,% 12d. <br /> GeneresPfwne arP°l.r Trl `-rba7n C �A <br /> �rYt,nati �m�. �1523�----- — <br /> 6.Transporter 1 Company Name - U.S.EPA ID Number <br /> 7.Transporter 2 Company Name U. EPA ID Number <br /> t-Y <br /> 8.Desi9n9kd�a��`N'jamo��nd Ste AQP /Lq/1 U.S.EPA ID Number <br /> FacGit�s Phones 17�Af�1 r1 1 0W13 CA10�Z��lO------------I <br /> 10.COrtleYtera 11.TOW 12.unit <br /> 9.Waste Shipping Name and Description No. Typrr Qtw ty WlNol. - <br /> o - - (Vm- 44 �nwk,��, oft C�` co,�V 5,�1 2 pM y da P - <br /> W <br /> w i 2' <br /> 13. Spega' f-Im 2d'and Additional Informacon - <br /> ��, <br /> 14.GENERATOR'SIOFFEROR'S CERTIFICATION:I hereby declare that the oonterds of He consignmed are fully and acourat*described above by the proper slrippi g name,and are ctassdad.penicaged, <br /> acarded.and are in el rospedt in poper can6tion for transport B=ring to applicable intemator and national governmental regulations. <br /> marked and latreled►pl _ <br /> GeneralorslOfferor s Prirted/T ,Na - Signalure---� - ---^ --- Month Day Year <br /> h.Inte rational Sf>ipnrents ❑ItrtpOrl to US. ❑Export Irom U.S. Po, a slat __-.-• - <br /> T rter S lure for ___Date leavig U.S.: <br /> -- -�. - <br /> cc 16.Tmnspoder Acknowledgment of Receipt of Materials ---- ---_----— - — <br /> T iter 1 P h1ed/T Name Signature Morith Day Year <br /> ° <br /> a <br /> N T er P iedfyped Name Signal le March Day Year <br /> cc <br /> 17.Discrepancy _ - - - -- — <br /> 17a.Discrepancy IndkaV Space_ ❑Quantity ❑Type ❑Residue ❑Partial Re;edicn ❑Full Reectcn <br /> Manifest Reference Number. <br /> 17b.Memato Facility(or Generator) U.S.EPA ID fdunrber <br /> U <br /> n <br /> Facifitys Phone: Month Day Year <br /> 17c.Signature of Alterna!e FadGty(or Generator) <br /> w <br /> W <br /> VDeso.4t�edFy Owner or Operator.Certification of receipt of materials covered by ft manifest exc�I as noted h item 17a — <br /> Print Name ) Signature - _- . j 6tentlr Day Year <br /> GC ei Printed in the USA F.M.. TO GF i of-I Reorder Partk MANIFEST-C6NHWC <br /> 01 z_anrY_aa�R <br />