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NON-HAZARDOUS 1.Generator ID Number 2.Pagel of S.Emergency Response Phone s 4,Waste <br /> WASTE MANIFEST 1,.1. ,t h j <br /> 5.Ganeratofs Name and Maging Address Tracking Number <br /> Genemlofs Slle Atldress to diderenl Ihen mailing address) ; <br /> Slrnl!frii Prndla G US cent®nfrHAA irk:WRok Fist"n Cord"Ranch-Harem ROAd <br /> Grim 00it orate iodine,trwo"Upob,IN 4C*78 1saoy I A <br /> Generalafe Phone: 74 ! 1, n <br /> 6.Trenspodef l Company Name <br /> Anletlaan ImpBrale�cl SOMMS,Inc, u.s.FaafD Namhe <br /> 7.Tranaponar 2 0ompany Name 'C CARWU1483t3Y38 <br /> U.S.EPA ID Numher - <br /> S.Desi�.:nyted..n Facility Name and Silo Address <br /> .:�'R6"„F ''111 t.'1='•�.'I <br /> U.S.EPA Ib Number <br /> Facili 's Phone: �TUr0, 'CA(fe M 926,458-IftI1 NQI RAr1h1hlit( <br /> e.Waste Shipping Name and Description 10.Containers 11.Tolal 12.Unil <br /> 1- No. Type Quantity W4Nol. <br /> 0 <br /> Nan-HfrxudounWpistR tiUtki(;;,Ufl} f7I CM <br /> U ' <br /> 3. <br /> 4. <br /> 13,Special HandOng Instmclions and AddllMnal Informagon <br /> RIPft�: 18238'! SAPdB(,748 <br /> ilhr ;rlHg41'rr;(iveecpl?Ianran9.1prI1i!ehGndET€)f, Iil�iljh3,nrtofufr, s InOldenl3C: 199AOS4CRAW060223 <br /> 1�m Np=7rrrxkYtuYca, t4lrQureiro?eft of yr rlumlyrr(NUlJj424 tr�{N➢ Pro( : X12167702 <br /> 4�hc:rrdlr.{r;• FrrirjxRrk: 7AU28�-12 <br /> 14.GENERATOq'S/OFFEgpq'S CERTIFICATION:I hereby declare that Iha contents of Ibis eonslgnmenl are fully ar�ec�urelely dascdbetl above by the proporshipplog name,and areclassilied,packaged, <br /> `;r marked end labeledlplacarded,enders In all respects In proper cnnditlon forlranspod according mapplicable interna final end national govemmenlat regulations. <br /> Generetofs/Oflerofa Pdnla ypis ame N <br /> Signature <br /> n AIS onbehaf iofOCOpUS,de,hermun <br /> -r 15.international Shipments <br /> ` <br /> El import to U.S. ` <br /> ❑Export from U.S. Pod of entrylew1 <br /> Tions fiats nature fares rts and <br /> x 16.TransporterAeknowiedgmenl of Receipt of Maledah Dale ledvin 'U.S.: <br /> .,: Transporter 1 P ledQyped Name ' <br /> SiAnelure / Month Day Year <br /> fi Transporter2 Pdnfer➢ryped Name <br /> SignaWre Momh pay , Yeer <br /> 17.Oiswepancy <br /> 77a.Discrepancy Indicalion Spars <br /> ❑QuanlAy ❑Type ❑Residue <br /> ❑Partial Fie)ecllan ❑Full Holliston <br /> 17b.Alternate Facility for Generator) Manifest Reference Numher. — <br /> U.S.EPA ID Number — <br /> V <br /> LL Facility's Phone: <br /> 17c.Signature of Alternate Fadlly(arGenemWr) <br /> z Month Day Year -I <br /> W <br /> ' O <br /> e <br /> f <br /> p 15.Designated Facility Owner orpperalor.Cerlilicalion of receipt of materials covered by the manlfest excels,as noted in Item 17a <br /> PdnledlTyped Neme <br /> 3lgnefure Month Day -Year+ <br /> 189-BLC-0 S 11977(Rev.9/G9) <br /> GENERATOR'S/SHIPPER'S INITIAL CO `r <br /> i <br />