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NON-HAZARDOUS 1,Generator 10 <br /> Nunber 2.Page I Of 3.Emergency Response Phone 4.Waste Tracking Number N f 0700894 <br /> _1i r R fl-M-)qR 0 1 1 <br /> WASTE MANIFEST I .I f E" I <br /> 5.Generator's Name and Mairing Address Generalor's Site Address(if different than melding address) <br /> Ghwipw Skxa No-37 alcorn wo -'V <br /> a <br /> Mull WPArtorA*,xa%Surwa 1,FaMidd.VA 01,11M, 3 !i Efoa Oma Lino ricy-A"'Wy.GJA <br /> Generators Phone: U.S,EPA ID Number <br /> 6.Transporter I Company Name <br /> mak"M I <br /> 7.Transporter 2Company ame U.S.EPA ID Number <br /> 8.D010terd M am Address U.S.EPA ID Number <br /> IRA <br /> 'at'-Wh-P-*aro Pali&Uaw <br /> Facility's Phone: Sahm-1-yrt,CA,UWRS <br /> 10.Containers 11.Total 12.Unit <br /> 9.Waste Shipping Name and Description No. Type Quantity WINO1. <br /> 'fier <br /> 2. <br /> co <br /> q <br /> 3. <br /> 4. <br /> 13.Special Handling Instructions and Additional Information <br /> wc-w law!U PPE whille or"aflawt am <br /> 14,GEN ERATOR'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 /> Generator's104ferDrs-Printed/Typed Name Signature Month Day Year <br /> _j 15.Intemational Shipments El Import to U.S. El Export fr..U.S. Port of entry/exit: <br /> Transpoorter Signature for exports ody): Date leaving U.S.: <br /> w16.Transporter Acknowledgment of Receipt of Materials <br /> I�Nn Day Year <br /> rr Transporter 1 PrinledtTyped Name Signature <br /> 0 1. 1 <br /> 0. 4/1"'111cci 7" , <br /> N ea <br /> z Transporter 2 PrWaTyped Name Signature p Month Day Year <br /> it <br /> 17.Discrepancy <br /> 17a.Discrepancy Indication Space 1:1 Quantity El Type El Residue ❑Partial Rejection ❑Full Rejection <br /> Manifest Reference Number. <br /> 17b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> Facility's Phone: <br /> w 17c.Signature of Alternate Facility(or Generataq Month Day Year <br /> zQr <br /> LL1 <br /> 18.Designated Facility Owneror Operator.Certification of receipt of materials covered by the manifest except as noted In Itorn 17a <br /> Printed/Typed Name Signature, Month Day Year <br /> 169-BLC-05 11977(Rev.9/09) GENERATOR'SISHIPPER'S INITIAL COPY <br />