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NON-HAZARDOUS 1•Generator ID Number 2.Page 1 of 3.Emergency Response Phone 4.Waste Tracking Number <br /> WASTE MANIFEST f 1&10-.1-1&— 77719 a 3a9i9- <br /> 5.Generators Name and Mailing Addr uP5 141417 14ew e x/140 I Generators Site Address(if different tha mSng a ress) <br /> 9s33o <br /> Generators Phone: <br /> 6.Transporter 1 Company Name U.S.EPA ID Number <br /> d 1A <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> 8.Designated Facility Name and Site Address,VoT15RO ���z4s �A1Q�j4 U.S.EPA ID Number <br /> _W <br /> Sal-suit/,. 95rs S-� J <br /> Facil s Phone: /V/ 4 <br /> 9.Waste Shipping Name and Description 10.Containers 11.Total 12.Unit <br /> No. Type Quantity WtJVol. <br /> a �jy�i7ivR d%�- �i� ` "'w'404cT <br /> ¢ <br /> z 2, <br /> w <br /> r, <br /> 3 - - <br /> Now r- <br /> 13.Special Handling Instructions and Additional Information fi v7o7GrJMAY 0 8 ` <br /> ENVIRONMENTAL HEALTH <br /> DEPARTMENT <br /> 14.GENERATOR'SlOFFFROR'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 /> Ge" tors/Offerors Printedfiyped Name ature Month Day Year <br /> 15.International Shipments ❑Import to U.S. ❑Export from U.S. Port of entry/exit: <br /> Transporter Signature for exports only): Date leaving U.S.: <br /> r2 16.Transporter Acknowledgment of Receipt of Materials <br /> ►' Transporter 1 PrintedfTyped Name Signature Month Day Year <br /> IL <br /> a9 �9 <br /> z Transporter 2 Printedfiyped Name Signature Month Day Year <br /> F I _ <br /> 17.Discrepancy <br /> 17a.Discrepancy Indication Space <br /> ❑Quantity ❑Type 1:1 Residue ❑Partial Rejection ❑Full Rejection <br /> Manifest Reference Number: <br /> 17b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> J <br /> U <br /> LL Facility's Phone: <br /> C' 17c.Signature of Alternate Facility(or Generator) Month Day Year <br /> w <br /> z <br /> z <br /> 0 <br /> to <br /> W <br /> O <br /> 18.Designated Facility Owner or Operat rtifi ion of receipt of materials covered by the manifest except as noted in Item 1 <br /> if Printed/Typed Name Signature M14 <br /> 169-BLS-C 6 10497(Rev.9/09) DESI ED FACILITY TO GENERATOR <br />