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4.WasteTracId NON-HAZARDOUS 1.Generator ID Number 2.Page 1 or 3.Emergency Response Phone 4.Waste Tracking Number mailing address WASTE MANIFEST 5.Generalors Name and Mailing Address Generators Site Address(if different than mailing address) 8191`4,1ItrNer 3t it 119 N.Ht rdur �.rr,r�rtlrr. (-A q2!>1`0" 81t7Ck1t117 l:�t 1J;yr41'l Generators Phone: 6,Transporter 1 Company Name U.S.EPA ID Number 7.Transporter 2 Company Name U.S.EPA ID Number .Tracking N 8.Designated Facility Name and Site Address U.S.EPA ID Number - cress) Facili 's Phone: 9.Waste Shipping Name and Description Noo.. Containers 11.Total 12.Unit Type Quantity Wt.Nol. Number 1. o Ffr1r.JJctaas,Nall I r()T Re Aa tKt Waula,BOW 'umb rere a ir Lu 2 imbb W 3. Unit /Vol. 4. 13. Special Handling Instructions and Additional Information 14.GENERATOR'S CERTIFICATION: I certify the materials described above on this manifest are not subject to federal regulations for reporting proper disposal of Hazardous Waste. Generatol's/Offeror's Printed/Typed Name Signature Month Day Year ri15.International Shipments F.- ❑Import to U.S. ❑Export from U.S. Port of entry/exit- z Trans offer Si nature for exports onl : Date leaving U.S.: w 16.Transpo ter Acknowledgment of Receipt of Materials oTransporter 1 Printed/Typed Name Signature Month Day Year a y Transporter Printed/Typed Name Signature Month Day Year 17.Discrepancy 17a.Discrepancy Indication Space ❑Quantity ❑Type ❑Residue ❑Partial Rejection ❑Full Rejection 17b.Alternate Facility(or Generator) Manifest Reference Number: J U.S.EPA ID Number U LL Facili 's Phone: 0 17c.Signature of Alternate Facility(or Generator) ! Month Day Year C7 rn w 0 18.Designated Facility Owner or Operator:Cerlificalion of receipt of materials covered by the manifest except as noted in Item 17a Prinled/Typed Name Signature Month Day Year v.. Y . ' Labels GENERATOR'S/SHIPPER'S INITIAL COPY