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NON-HAZARDOUS 1 Generator ID Number 2.Page 1 of 3.Emergency Response Phone 4_Waste Tracking Number <br /> WASTE MANIFEST 4',#a$3i1&i _iT;a <br /> 5.Generators Name and Mailing Address Genarator's Site Address(it different than mailing address) <br /> � t s*-Jitse (o rgs"w T:r.r+ t't4.a tikr1 # l vary T'4t€€s1#"Sfhw- <br /> R <?4>d'mryKrrar ter±vV ��M t=':cu kmex'+�#ta lyk)a5 kd. <br /> sn a�at T4cas.= i'. ,. k9rh:r a SaWt #axxr I r ac e. 'A <br /> Generator's Phony=,;1;, � s' <br /> 6 Transporter 1 Company Name U.S.EPA ID Number <br /> 7.Transporter 2 Company Name U.S,EPA ID Number <br /> 8,Designated Fadtily Name and Site Address U.S.EPA ID Number <br /> :3'-44fc "II:Xr e j a=saw at 40.%in A'44 I <br /> 1(w,ip.%Paws-w T i�%fi>B4vj <br /> 1 4 4 ?x;31 <br /> 9.Waste Shipping Name and Dascriplion 10.Containers 11.Total 12,Unit <br /> No, Type Quantity WtJvol. <br /> t. 3 <br /> tt-0f r i-, >es= V1 <br /> a <br /> Lu 2 <br /> cs <br /> 3. <br /> ..,..... — <br /> 4. <br /> _ r <br /> 13-Speclal Handling In31ruC#on6 and Additional Information <br /> fi`614$�i7412 <br /> V 'Nit.. <br /> Nvkr,^at*fSxarr <br /> 14.GENERATOR'SIOFFEROR'S CERTIFICATION:1 hereby declare that the contents of this consignment are fully and accurately described above by the proper shipping name,and are classified,packaged,;, <br /> marked and labeledrplacarled,and are in al;respeel5 in proper oonfton for transport according to applicable international and national governmental regulations. <br /> Generalor'vOiferors PrinledlTyped Name Signature Month Day Year <br /> yr' <br /> 15.International Shipments ❑Import to U.S. El Fxporcfinm U.S. Port of entryledt: <br /> z Transporter Signature lcr oat Date leaven U.S.: <br /> 16,Transporter Acknowledgment of Receipt of Materials <br /> F Transporter 1 Pnnted,Typed Name Signature Month Day,,, Year <br /> Z Transporter 2 PrintedlTyped Name Signature Month Day Year <br /> 4 <br /> 17.Discrepancy <br /> 178 Discrepancy Indication Spacej <br /> ua i �~ - ❑PaPartialEJial tleection �Full RejeGion <br /> 11 <br /> ManiLN Roteream Number: <br /> 17b Alternate Factty(a Generator} U S,EPA ID Number <br /> JIJ�f 4ll� 2? y <br /> ua Facility's Phoner t r 1 <br /> 17c.Signature of Alternate facility(or General Month Day Year <br /> z <br /> 43 <br /> 16.Designated Facility Owner or Operator:Ceri ication of receipt of materials covered by the manifest except as noted in item 17a <br /> PrintedrTyped Name _ Signature Morrlh Day Year <br /> 169-BLC-O 6 10498(Rev.9109) GENERATOR'S/SHIPPER'S INITIAL COPY <br />