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NON-HAZARDOUS 1.Generator ID Number 2.Page 1 of 3.Emergency Response_f'(;one.�, 4.Waste Tracking Number f: r <br /> WASTE MANIFEST IQT N:;Q1.:''tEr,I <br /> 5.Generators Name and Mailing Address Generator's Site Address(I different than mailing address) <br /> E( ppdi P�t�,3. AV...t:1i <br /> ill:�i'.Ij $x}Jr 6i..'1.a{fs ^ � Uii A. EYI Wr+J i'1-' ii <br /> Generator's Phone: <br /> 6.Transporter 1 Company Name U.S.EPA 10 Number <br /> ' I G•'nf ; <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> 8.Designated FpaclkNan antSile AVress U.S.EPA ID Number <br /> ince Rr.,ts.;--I <br /> Facilitys Phone: C " <br /> 9.Waste Stripping Name and Description 10.Containers 11.Total 12.Unit <br /> No. Type Quantity WINd. <br /> 1. ` <br /> W <br /> ���. . <br /> W 2. / <br /> 0 <br /> 3. <br /> 4. <br /> 13.Special Handing Instructions and Additional Information <br /> '!1,vN pvrt -_,r i`;f' ftafty'g. VVC-erPft or t.*dwrr.ire <br /> gT,77x,:.r D. 24 PrjwafTzTmyrttknT (CCS).:2-2-fiwS <br /> 14.GENERATOR'SlOFFEROR'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 intematlonal and national governmental regulations. <br /> Generjtgl'slO r's�P«4e 7 edJ fYi ,j Y:XTC?ii'7 Signature Month Qay Year <br /> 3 15.international Shipments ❑Import to U.S. ❑Export I.U.S. Port of entryle)dt <br /> TranspWer SI nature for exports only): Date leavin U.S.: <br /> oc 16.Transporter Acknowledgment of Receipt of Materials f k f <br /> ¢ Transporter 1 Printed/Typed Name (' - // Signature `'/ / Month Day Year <br /> IL <br /> Z Transporter 2 PdntedlTyped Name Signature ' 1/ Month Day Year <br /> 17.Discrepancy <br /> 17a Discrepancy Irxkratbn Space Quantity 1:1Type ElResidue ❑Partial Rejection ❑Full Rejection <br /> Manifest Reference Number. <br /> 17b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> Facility's Phone: <br /> 17c.Signature of Alternate Facility(or Generator) Month Day Year <br /> z <br /> is <br /> y <br /> W <br /> G � <br /> I B.Designated Facility Owner or Operator.Certification of receipt of materials covered by the manifest except as noted In Item 17a f <br /> Prkntedffyped Name (; y _ Signature t Month Day YOU <br /> TRANSPORTER#1 <br /> 169-BLC-0 5 11977(Rev.9/09) 1) i <br /> r <br />