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NON HA7ARDOUS <br /> �1.Generator ID Number 2 Page 1 of A3.Emergency Response Phone 4.Waste Tracking Number <br /> ,1AfASTit'MANIFEST ^. <br /> 5.Generator's Name and Mailing Addre Gerieratar's rte Address(i -ifferent than mailing address <br /> IL3" Cl`�'�p✓ ".a:J :;1733 "` �... <br /> lit 13 <br /> GerkMokFie7V� '�� S �r U.5.EPA ID Number <br /> 6.Transporter f Company Name <br /> U.S.EPA ID Number <br /> 7.Transporter 2 Company Name <br /> U.S.EPA ID Number <br /> 8.Designated Facility Name and Site Address <br /> 93117 <br /> Faril"s Phb1Te" <br /> 10.Containers 11-Total 12.Unit _- <br /> 9a 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, W1JVal. <br /> HM and Packing Group Cd any)) No. Type Quantity <br /> cc W�4 <br /> m : ' <br /> 2 2 <br /> LU <br /> 3. ` <br /> 4. r . <br /> 13. Spedsal Handling Instructions and Additional Information <br /> DI-i i Y a'i <br /> aiant -107,914 <br /> 14.GENERATOR'S CERTIFICATION:I certify the materials described above on this manifest are not subject to federal regulations Signature <br /> for reporting proper disposal of Hazardous Waste. Month Day Year <br /> " <br /> Generatoes/Offerofs PrintedlTyped Name Slg <br /> .j 15.International Shipments .~1 ❑Export from U.S. Port of eniryleAd: <br /> ❑Import to U.S. <br /> ;rens iter Signature for exports only): Date leaving U.S.: <br /> w- 16.Transporter Acknowledgment of Receipt of Materials Month Day Year <br /> Trran�orter t Printed/Typed Name Signature ;�r <br /> 0. - <br /> N f .. Slgnawre;sr Month Day Year <br /> Z Transporter 2 Printedlryped Name <br /> ccH <br /> 17.Discrepancy <br /> 17a.Discrepancy Indicafion Space ❑Quantity ❑Type ❑Residue ❑Partial Rejection F0 Rejection <br /> Manifest Reference Number. <br /> U.S.EPA ID Number <br /> 17b.Altemate Facility(or Generator) <br /> S.1 <br /> LL Facility s Phone: Month Day Year <br /> w 17c.Signature of Alternate Favi ft(or Generator) <br /> _R <br /> rL + J 'Rk'ss 3a 8#xgD ^ffi- BAXa d H roX - <br /> 18.Designated Facility Owner or Operator.Certification of rec6pt of hazardous materials covered by the manifest except as noted in Item 17a Month Day Year <br /> PdmadlTyped Name Signature <br /> GENERATOR'SISHIPPER'S INITIAL COPY <br /> 169-BLC-0 6 10498 <br />