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,._ . <br /> NON-HAZARDOUS I.Generator ID Number 2.Page 1 of 3.Emergency response Phone 14.Waste Tracking Number F j ()r)T.", <br /> WASTE MANIFEST til"-)T; s=t'Lr ',tf�' i _ E'. ,-�?': .Y:N.� `I <br /> 5.Generators Name and Mailing Address Generator s Site Address(if mferent than mailing address) <br /> Generators Phone. <br /> 6.Transporter 1 Company Name U.S.EPA ID IVurnber <br /> 7.Transpo to m <br /> 2 Con. U.S.EPA ID Number _-- <br /> 8.Dgsignaled Facility N e and Site Address U.S.EPA ID Number <br /> 175 <br /> Fadli 's Phone: <br /> t,+(',s,.W5145 <br /> 10.Containers 11.Total 12.Unit <br /> 9.Waste Shipping Name and Description No. Type Quantity Vdt.Nol. <br /> 1. <br /> :`t ..`?"vet :`.�°it'`P3 t^_^ tilt.' <br /> z1 <br /> ! t <br /> w <br /> Z <br /> 2. <br /> •1 <br /> 3. <br /> 4. <br /> 13.Special Handling Instructions and Additional Information <br /> 14.GENERATOR'SIOFFEROR'S CERTIFICATION:I hereby declare that the contents of this consignment are fully and accurately described abode by the proper shipping name,and are classified,packaged, <br /> marimd and labeled/placarded,and are in all respects in proper condition for transport according to applicable international and national governmental regulations. <br /> Generators/Offerors P`ntedfTyped Name r.. Signature ;' Month Day Year <br /> 15.International Shipments ❑Import to U.S. ElP <br /> Export from U.S. Pod of entrylexic <br /> Z Trans orter Signature for exports only): Dale leavin U.S.: <br /> w <br /> 16.Transporter Acknowledgment of Receipt of Materials <br /> r— Transporter 1 Printed/Typed Name Signature Month Day Year <br /> 0 ! � �. <br /> ° , ,fin<_c, fr��!�tL. ►A-�c, = 7,1A .� S <br /> i Month Day Year =' <br /> z Transporter 2 Printedffyped Name Signature ' p, <br /> H <br /> 17.Discrepancy <br /> 17a.Discrepancy Indication Space ❑Type ❑Residue ❑Partial Rejection ❑Full Rejection r <br /> ❑Quantity <br /> ;q <br /> Man'fiest Reference Number. <br /> t}- 17b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> J <br /> U ` <br /> tQi Facility's Poona: <br /> Lu 17c.Signature of Altemate Facility(or Generator) rro„m Day Year r, <br /> z <br /> z <br /> cs <br /> m <br /> U.1 <br /> p r <br /> 18.Designated Facility Owner or Operator.Certification of receipt of materials covered by the manifest except as noted in Item 17a ; <br /> Signature Iviont Day Year <br /> Prinled i ed Name _ <br /> 169-BLC-0 5 11977(Rev.9/09) } TRANSPORTEA#1 <br />