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�1Ad NON-HAZARDOUS 1.Generator ID Number 2.Page 1 of 3.Emergency Response Phone 4.Waste Tracking Number WASTE MANIFEST CAD 12 'a0 1 7,1 � � ]'�_;�? �-.7 a'�7 5 4 4,153—:I 5.Generator's Name and Mailing Address Generator's Site Address(if different than mailing address) i L•E__,7 L...`3 9134 1 (3:9 3 '?54"'„} 11 Generator's Phone: 6.Transporter 1 Company Name U.S.EPA ID Number, 1 is 0&A W T:-C:-_A Is Tnc. 7.Transporter 2 Company Name U.S.EPA ID Number 8.Designated Facility Name and Site Address U.S.EPAIDNumber Facilit es Phone: 9a. 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 1r1.Containers 11.Total 12.Unit HM and Packing Group(if any)) No. Type Quantity .WtJVol, O JTf 1 sa W2 C7 - IM 13. Special Handling Instructions and`AcIffonal Informal on t �rT4to-!i`��a ?.silt tf 9” '..ateA CA s?1 14.GENERATOR'S CERTIFICATION:I certify the materials described above on this manifest are not subject to federal regulations for repordng,proper disposal of Hazardous Waste. Gengratorsl0fferorslntedliypedName Signatures''f` r'. ' Month Day F is.International Shipments ❑Import to U.S. ❑Export from U.S. Port of entry/ext Transporter Signature for exports only): Date leaving U.S.: 16.Transporter Acknowledgment of Receipt of Materials. Transporter 1.PrintedfTyped Nacn .e Signature , Month, Day Year i f p0, ,. '� Y�,/ .`['<.,G�L- � z'if f... F>ti }..„' y±'G�- %�r-� _f 0 Z Transporter 2 PrintedlTyped Nae Signature Month Day Year r 17.Discrepancy 17a.Discrepancy Indication Space Residue ❑Partial Rejection ❑Full Rejection ” ❑Quantity Type - Manifest Reference Number. - 17b.Altemate Facility.-(or Generator) U.S.EPA ID Number , U rat Facility's Phone: 17c.Signature of Alternate Facility(or Generator) Month•,.Day Year 0 k N y m t _ 18.Designated Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except as noted in item 17a - Printed)Typed Name Signature Month Day Year 169-SLC-0 6 10498 GENERATOR'S/SHIPPER'S INITIAL COPY;