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I <br /> i NON-HAZARDOUS I•Genaral"Number2.Page 1 of 3.Emergency Response Phone 4.Waste Tracking Number <br /> WASTE MANFEST NOT APPLICABLE 153819 <br /> S.Generator's Name and Mailing" 9 Address Generelor9 Site Address(if different Than maifmg address) <br /> Ato 3�100� 24.3! �, . �, -t, <br /> 71%2. �zh R41 . S�tk_PA CA '152 I'S <br /> Generator's Phone: u C k. vr� <br /> 6.Transporter 1 Company Name 'r US.EPA ID Number <br /> Z� —Eruckiota c. NOT APPLICABLE <br /> 7.Transposer 2 Company Name U.S.EPA ID Number <br /> i NOT APPLICABLE <br /> 8.Designated Facility Name and Site Address U.S.EPA ID Number <br /> f ir_L.(_�L�•t.:Y' HAY 10AD NOT APPt_'CABLE <br /> IW6 H"ROAD -VA'11•,.:f; `,a nrA37 <br /> Facili s Phone: <br /> a H <br /> 9.Waste Shipping Name and Description 10.Conters 11.Total 12.Uit <br /> No. Type Quantity WtNnol. <br /> 1. <br /> cc <br /> C• 1 <br /> O <br /> of J <br /> W <br /> 2. <br /> I Cil <br /> I <br /> MP <br /> � <br /> 4. vo <br /> N ^�A"rcr <br /> 13.Special Handling Instructions and Additional Information <br /> I I <br /> ��3900 9a ' <br /> 14.GENERATOR'SIOFFEROR'S CERTIFICATION:I hereby declare that The contents of this consignment are fully and accurately described above by die proper shopping name,and are classified,packaged, <br /> marked and labeledlplacarded,and are in all respects in proper condition for transport according to applicable international and national governmental regulations. I <br /> Generatofs/Ofleror's Print6d/Typed Name Sign-lure _ __ Month Day Year <br /> tel! J�.1t2rvrlr _ ��y L1G - -- ZI <br /> j 15.Inlematla(ai Shipments <br /> IF- ❑Import to U.S. E pod from U.S. j Pod of entrynexit i <br /> Transpo rter Signature for exports on!y): Date leav U.S- <br /> cc 16.Transporter Acknowledgment of Receipt of Materials <br /> 7 <br /> ¢ Transpo�lor 1 Printedrryped Name S Month Day Year <br /> j <br /> IL <br /> a Transporter 2 PrintedrTyped Name Signature Month Day Year <br /> cc <br /> F <br /> 17.Discrepancy <br /> 17a.Discrepancy Indication Space ❑Residue ❑Partial Rejection{ ❑Quanliy L1 Type le ❑Full Rejection <br /> _ Nanilesi Reference Number. <br /> 17b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> I <br /> i U <br /> LL Facility's Phone: <br /> C3 17c.Signature of Ademala Facility(or Generator) Month Day Year <br /> a � I <br /> Z <br /> t:7 <br /> rn <br /> W <br /> D <br /> 18.Designated Facility Owner or Operator:Certification of receipt of materials covered by the manifest except as noted in Item 17a <br /> Printed(Typed Name Signature / /"15• Month Day Year <br /> r <br /> 169-BLS-C 5 11979(Rev.9/09) DESIGNATED FACILITY'S COPY <br />