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NONHAZARDOUS 1.Generator ID Number 2.Page 1 of 3.Emergency Resporae Phone - 4.Waste Tracklrg Number <br /> WASTE MANIFEST <br /> 5.Generator's Name and MaCing Address Generator's Site Address(if different than mafling address) <br /> r,?`�rl�:—�O.l�''i y�` i� t e� f i`!-PyZ �.� ('U£•.�3,�t:':6� .':.1. a ` 1{.� <br /> 7?,iilfL.jr`3:�'l�:, is_•�'.�6� . k f`f {..3sI�L,k ��31Y��lD� �.1!°`.3 i .:�{i}i �rt. •i �i�.l <br /> Generator's Phone: <br /> 6.Transporter 1 Company Name U.S.EPA ID Number <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> 8.DesiKated Fac7ity Narpe and Site Address U.S.EPA ID Number <br /> FacTl s Phone: f` lv'1: ,�''�1 C 4665 `.':%.0 <br /> 9.Waste Shipping Name and Description 10.Containers 11.Total 12.Unit <br /> No. Type Quantity Wt.Nol. <br /> t. <br /> f E4r ti i � i LFI 'VI `fa llc e:: '1'a 'i �,` .1�� � } � ��,� � �{�L <br /> UJ <br /> 2• <br /> 3. <br /> 4. <br /> 13.Special Handling Instructions and Additional Information <br /> vMp.,n fn�f 91.•�L V t-�'Rit cc IV`.kms <br /> 2. 1>`'X.t' (6rl lj42 " <br /> txtv,; [w: 'Jv,�tar.', fit <br /> 14.GENERATOR'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 dassffied,packaged, <br /> marked and labeled1placarded,and are in al respects in proper condition for transport according to applicable international and national governmental regulations. <br /> GeneratorslOfr�Y£�FtlM�gc�rTa�rike�,t��� J Sh. r <br /> Signature Month Day Year <br /> -J 15.International Shipments ❑import to U.S. ❑Export from U.S. Port of entrylexib <br /> t Transporter Signature for exports only): Date leaving U.S.: <br /> w16.Transporter Acknowledgment of Receipt of Materials <br /> Transporter 1 Printedfiyped Nama �r i Signature /7`� f Monith Day Year <br /> Transporter 2 PrintedlTyped Name Signature f Month 'Day Year <br /> 17.Discrepancy r <br /> 17a.Discrepancy Indication Space <br /> ❑quantity ❑Type ❑Residue ❑Partial Rejection ❑Full Rejection <br /> Manifest Reference Number. <br /> } 17b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> � I <br /> a Facility's Phone: <br /> w 17c.Signature of Alternate Facility(or Generator) Month Day Year <br /> a <br /> z <br /> y <br /> W <br /> O , <br /> 18.Designated Facility Owner or Operator:Certification of receipt of materials covered by the manifest except as rated In Item 17a r <br /> PriMedryped Name �F r, I j i f '1 Signature Month Day Year <br /> if <br /> 169-BLC-05 11977(Rev.9/09) TRANSPORTER#1 <br />