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i' <br /> NON-HAZARDOUS 1.Generator ID Number 2.Page 1 ofr31nmergericy Response Phone 4.Waste Tracking Number <br /> WASTE MANIFEST - - - <br /> 5,Generator's Name and Mailing Address Generator's Site Address(it different than mailing address) <br /> s <br /> ts,,f;"w"*-t`4pwr, azfi S »�,E,ta 0°ec9 t'i m4j4 SOA6z a <br /> 1,.tazragaw„rr6"v A." =15r..=P. nzx n9ei?ex-r a. r ssaff-ws �.-�C�..E <br /> O's VC, <br /> Generator's Phone,:MVt 14 4` 4`1U, <br /> 6.Transporter 1 Company Name U.S.EPA iD Number <br /> 01 �'4tat'.E S's r<iz t«s <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> 4 <br /> 8.Designated Facility Name and Site Address U.S.EPA ID Number ) <br /> FaGlit'sPhone: : ' c.a "- 'atiAt <br /> 10.Containers 11.Total 12,Unit <br /> I 9.Waste Shipping Name and Description <br /> No. Type t]uantihy WINoI. <br /> 1 <br /> ¢0 e na 04 it i k <br /> 2. <br /> 0 <br /> 3 z3 <br /> 1 <br /> 13.Special Handling Instructions and Additional Information <br /> A" �s a {'. i14 kT.zt11c 1Y �'Az:ee Ez $':'3 `2'. ..*i -_ ,✓ ,.i d.xr ... ' <br /> 14.GENERATOR'SIOFFEROR'S CERTIFICATION:I hereby declare that the contents of this consignment are fully and accurately described above by the proper shipping name.and are cfassilied,packaged. <br /> marked and tabatediptacarded,and are in all respects in proper condition tor transport according io applicable intemabonal and national governmental ragulallons. <br /> GeneratorsOf(erar`sPrintedrTypedName Signature Month {day Year <br /> _r 15.International Shipments 1 <br /> import to U:S. ❑Export from U.S. Port of entryut - <br /> Transporter Si nature for exports only): Date leavi U.S.: <br /> cc 16 Transporter Acknowledgment of Receipt of klawdats <br /> us <br /> Transporter 1 Printed Typed Name Signature Month Day Year <br /> cc0 <br /> 6 Transporter 2,Printed!Typed Name Signature Month Day Year <br /> I- <br /> 17,Discrepancy ' <br /> 17a.Dfscrepancy Indication Space ❑Quan Type ❑Residua ❑Partial Rejection ❑Full Rejeefti <br /> 4 r " Manifest Reter'erice Number: <br /> r 17b.Allernafe Facility(or Generator) U.S.EPA ID Number <br /> rail Facility's Phone: y 4f <br /> 17c.Signature of Alternate Facility dor Generator) r I '" Month Day Year <br /> a <br /> z �. <br /> m _ <br /> w <br /> N � <br /> -------------- <br /> 18.Designated Fadlity Owner or Operator.Certification of receipt of matertals covered b p <br /> the manifest exce t as noted in Item 17a <br /> PrintedlTyped Name Signalure Month Day Year <br /> 169-BLC-0 6 10498(Rear.9109)-- — GENERATOR'S/SHIPPER'S INITIAL COPY <br />