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7 r � f <br /> 6 32� <br /> NON-HAZARDOUS 1.Generator ID Number - 2 Page 1 of 3.Emergency Response Phone. 4.Waste Tracking Number <br /> WASTE MANIFEST i 40T At'r!_.1G ii...: <br /> lq 23 <br /> 5.Generators Name and Mailing Address Generator's Site Address(if different than mailing address) <br /> Cad ��ass dOc� ��io 3po�C s i ,�� . <br /> N- r.1A U- GPS grJ21� 1, <br /> G( 210 - VAL <br /> 6.Transporter 1 Conf7 Name U.S.EPA ID Number ( <br /> - v`G• NOT APPLICABLE: <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> NOT APPLICABLE <br /> B.Designated Facility Name and Site Address U.&EPA ID Number <br /> REC(,rt.0GY HA'f ROAt #'f)T APPLICABLE <br /> 8426 HAY ROAD V ACAV II <br /> Fadii s Phone: 678-4718 <br /> 9.Waste Shipping Name and Descripticn 10.Containers 11.Total 12.Unit <br /> No. Type Quantity WWol. <br /> cc <br /> 1. <br /> t 1 <br /> Z 2 <br /> W <br /> L r I <br /> 3. r -- <br /> 4. <br /> I <br /> j <br /> 13.Special Handling Instructions and Additional Information <br /> I rL C�r r• i <br /> i <br /> I <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 classified,packaged, <br /> marked and labeled/placarded,and are in all respects in proper condition for transport according to applicable international and national governmental regulations. <br /> Generators/ONeror s Printed/Typed Name 1 Si9-ture Mont/h Day Year <br /> �._ `'C' it►• �I _ �.� Z.•- J s: IJ <br /> 15.International S gmenls <br /> z ❑Import to U.S. ❑Fxpart from U.S. y ort of et"lexB: <br /> Trans orter Sionature for exports only): Date leaving U.S.: <br /> ¢ 16.Transporter Acknowledgment of Receipt of Materials <br /> Transporter 1 PrydAd Toped Narge Signature Month Day Year <br /> Trarispodw 2 Prim ffl`yped Node "L~ Signature Month Day Year <br /> cc <br /> i <br /> 17.Discrepancy _ <br /> 17a.Discrepancy Indication Space <br /> ❑OueruMy ❑Type ❑Residue El Partial Rejection ❑Full Rajectbn <br /> Manifest Reference Number. <br /> r 17b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> v <br /> Facility's Phone: <br /> W 17c.Signature of Alternate Facility(or Generator) Month Day Year <br /> Z <br /> O <br /> to <br /> W <br /> 0 <br /> I <br /> 13.Designated Facility Owner or Operator:Certification of receipt of materials covered by the manifest except as rated in Item 17a <br /> Printed/Typed Name ' - C \Signature %+ IVIC ay year <br /> ar <br /> _ I <br /> 168-BLS-C 5 11979(Rev.9109) DESIGNATED FACILITY'S COPY <br />