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' 4.Waste Tracking Number <br /> 4.Generator ID Number 2.Page 1 of 3.Emergency Response Phone g ,a 1 <br /> N0N-HAZARDOUS ', f'•# <br /> WASTE MAN] EST �" ►I <br /> 5.Generators Name and Mailing Address Generators Sne Address(it diverent than mailing add(eSS) <br /> �`.:9,1f'. M r. 7a•s•"'),� .':f.�`t;.•d'�;'ti;,: t <br /> Generator's Phone: U.S.EPA ID Number <br /> 6.Transporter 1 Company Name <br /> g. !, ,.,_. , .t e. <br /> U.S.EPA ID Namber <br /> 7.Transporter 2 Company ame <br /> B.Dgsrgnated FacTty,Name and Site Address U.S.EPA ID Number <br /> Fadli 's Phone: <"."`?t 1, -�: <br /> 10.Containers 11.Total 12.Unit <br /> 9.Waste Shipping Name and Description No. Type Quantity Wt.Nol. <br /> 1. <br /> W <br /> z 2. <br /> Lu <br /> 3. <br /> 4. <br /> 13.Special Handling Instructions and Additional Information <br /> µ- <br /> :pa y�;�._. f.n,.. i rrI .�.•.p- .i - %`i-E4 ,g �. '7�,^.�rt...:�.�1--�.'Y• ��� .3 <br /> s i Lr-' �..a 7.! a '. .. !.:�is Mt�.� :i� na.3 srii �...'zi�i.•.:i+�.':s. , <br /> .ti"<""t.`i {-z f T w;T'".'E';yt <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 /> manced and labeled/placarded,and are in all respects in proper condition for transport according to applicable international and national governmental regulations. <br /> Generator'slOfferor'sfrnted/TypedName ( Pr Signature �f r Month Day Year <br /> ri <br /> F- 15.International Shipments ❑Import to U.S. ❑Export from U.S. Pon of enhyleait <br /> z Transporter Signature for exports only): Date leaving U.S.: <br /> ¢ 16.Transporter Acknowledgment of Receipt of Materials <br /> jiTransporter 1 PrintedlTyped Name Signature month Day Year <br /> Nac { 7 <br /> f�{.��Mfr �'{d`�'�c!..�" e"F. •^ ��.,��'s"! �t^�-"'. Iw., I l; <br /> z Transporter 2 Printedlryped Name Signature Month Day Year <br /> ccI— <br /> '� <br /> 17.Discrepancy <br /> 17a.Discrepancy Indication Space <br /> ❑Quantity ❑Type IJ Residue ❑Partial RejeGion ❑Full Rejection Y <br /> rz <br /> Manifest Reference Number. 4. <br /> t.- <br /> 17b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> U e. <br /> rat. Facility's Phone: <br /> W 170.Signature of Alternate Facility(or Generator) Month gay Year <br /> a <br /> Z <br /> cs <br /> • w <br /> 0 <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 _ — Moran Day Year <br /> 169-BLC-0 5 11977(Rev.9109) TRANSPORTER#1 <br />