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ous 1.Generator ID Number T2 Page 1 of F13.—Emeganct,Resporise Phone 4.Waste Tracking Number -HAZARl NON D WASTE MANIFEST 5.GeneratDfs Name and Mailing Address Generato(s Site Address(if(Afferent than mailing address) 7 lit . 4 t .-LI Generators Phone: 6-Transporter I Company Name U.S.EPA ID Number 7.Tra sporlor 2 Company Name U.S.EPA ID Number 8.Designated Facility Name and She Address U.S.EPA ID Number ?UT, G—,��Ior ID Number MANIFEST 5. Facility's Phone: 10.Containers 11.Total 12.Unit 9.Waste Shipping Name and Description No. Type Duartity WiJV(A. irww�a LkU4 it 0 2. 3 r. 4 4. V 13.Special Handling instructions and Additional Information -4 27A 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,pacraged, marked and labeled1placarded•and are in all respects in proper condition for transport according to applicable International and national governmental regulations. -denerator'sDfferoes PrintecilTyped Name Signature Montri Day Year t if — I — ! r r // -j 15.International Shipments ❑Import to U.S. ❑Export from U.S. Port of entry/exh: Transporter Signature for exports only): Date leaving U.S.: cc 16.Transporter Acknowledgment of Receipt of Materials Ev Lu fla I-- Transporter 1 Printed/Typed LNarne Signature Month Day Year 0. Er A 0 4 a ('6 1 44, Transporter 2 Printed[Typed Name Signature Month Day Year cc 17.Discrepancy 17a.Discrepancy Indication Space El Quantity ElType ❑Residue Ll Partial Rejection ❑Full Rejection cis Manifest Reference Number 17b.Alternate Facility(or Generator) U.S.EPA ID Number :3 0 11 Facility's Phone: 0 Day Year uj 17c.Signature of Attemate,Facility lot Geneiator) Month Z CS Lu 18.Designated Facility Owner or Operator.Certificaflon of receipt efmaterials covered bythe manifest except as noted in lieni 17a SignatureMonth Day Year PrintediTyped Name I RANSPORIER #1 169-BLC-0 5 11977(Rev.9109)