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NON HAZARDOUS 1 Genara`or ID f t mbar 12.Page 1 of ,'•.Emergency Response Phone racking Nu <br /> 4.Waste Tmbee <br /> Number y� t <br /> WASTE MANIFEST <br /> 5.Generators Name and Mailing Address Generatur s Site Address(if different than mailing address) ,> <br /> i< ,t.,..r r� ?; A�s1:7 t <br /> Generator's Phone: <br /> 6.Transposer 1 Company Name U.S.EPA ID Number <br /> a. •k. <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> �z <br /> r:. <br /> B.Designated Facility Name and Site Address U.S.EPA ID!Number <br /> Facitit s Phone: (' `•:! 1, [:. of 3 t :°" x <br /> 10.Containers 11.Total 12.Unit <br /> 9.Alas'e Shipping Name and Description �No. Type Quantity WIJVol. <br /> cc <br /> 0 1 .44.:.. Wa "2 l t1U=1 <br /> W -7j <br /> w 2 t:r <br /> 3. {i <br /> 4. <br /> 13.Special Handling Instructions and Additional Information <br /> 'f iE <br /> 7.'m LE t`�-r•; -.t.. r �4t•�-i.4�. -w. [:-.f4' .a 4�i. .,� .5 yt+*. SY'.wt.:E€... .�i.i ..� ` _� . <br /> W7573 <br /> A <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 Bassi fed,packaged, k <br /> marked and labeledlplacarded,and are in all respects in proper condition for transport according to applicable International and national governmental regulations. <br /> Generator'slOfferoes PdnfedlTyped Name Signature f: f Month Day Year <br /> —r 15.International Shipments <br /> i ❑Import to U.S. ❑Export from U.S. Port of entry/exit <br /> z <br /> Transporter Signature for exports only): Dale Ieavinu U.S.: <br /> ac 16.Transporter Acknowledgment of Receipt of Materials <br /> Transporter 1 Printed/Typed Name SignatureMonth Day Year <br /> k,_ S 3a <br /> aTransporter 2 Printedlryped Name Signature Month Day Year , <br /> r- <br /> 17.Discrepancy <br /> 17a.Discrepancy Indication Space <br /> ❑Quantity El Type El Residue ❑Partial Rejection Full Rejection <br /> .4 <br /> Manifest Reference Number: <br /> "U <br /> 17b.AlternateU.S.EPA ID Number <br /> Alternate Facility(or Generator) t; <br /> J <br /> V <br /> rQi Facility's Phone: <br /> Lu 17c.Signature of Aliemate Fadlity(or Generator) MonthDay Year <br /> W <br /> 18.Ocsignafed Facility Owner or Operator:Cedification of receipt of materials covered by the manifest except as noted in Iter,17a <br /> Printedpf ped Name Signature Month Day Year <br /> 169-BLO-0 5 11977(Rev.9/09) TRANSPORTER#1 <br />