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NONHAZARDOUS 1.Generator ID Number ✓ 2.Page 1 of S.Emergency Response Phone 4.Waste Tracking Number <br /> WASTE MANIFEST h4OTREQURr.,�ll 1 M-423-6M 1 0700666 <br /> 5.Generator's Name and Mailing Address Generator's Site Address(if different than mailing address) <br /> RAP966 CkiFrtf4lyt E"cow Its Wim Na. 111 <br /> Generators Phone: <br /> 6 Transporter 1 Company Name U.S.EPA ID Number <br /> BriVem,khm C' r1ITU <br /> 7.Transporter 2 Company Name �. � U.S.EPA ID Number <br /> B.Designated Facility Name and Site Address U.S.EPA ID Number <br /> KBIN Vkhy x't LsaKM. <br /> 901 BfAtsy RrAd Not RequkW <br /> Facility's Phone: FWjftn CA 9456.5r V`.5-4554M <br /> 9:Waste Shipping Name and Description 10.Containers 11.Total 12.Unit <br /> No. Type Quantity Wt1Vol. <br /> cr <br /> 1. <br /> CC <br /> . Nan-��fC 4 W*&�7 ( 4) DM <br /> w <br /> w 2. myr <br /> a <br /> 3. <br /> 4. <br /> As. <br /> 13.Special Handling Instructions and Additional Information <br /> W p€ we Ya fgtt pnwt a t'e"aatt�FoV.Xwt�is vt unwo-4 <br /> l <br /> s4.spKt Atl mit. 24 he a i 1im1woy tTunthr(834*)423 �Prc cal y. d 2tfltl4�ka 4?2 <br /> E�rtial. 74f1001 4'-19 <br /> 14.GENERATOR'SIOFFEROR'S CERTIFICATION:I hereby declare that the contents of this consignment are idly and accurately described above by the proper shipping name,and are classified,packaged, <br /> marked and labefedlplacarded,and are in all respects in proper condition for transport according to applicable international and national governmental regulations. <br /> Generator's/Offerces Pranted/W Name Signature Month Day Year <br /> J .sem <br /> 15.International Shipments <br /> i- ❑Import to U.S. ❑Export from U.S. Port of tritryle' <br /> Transporter Signature for exports only): Date leaving U.S.: <br /> cc 16.Transporter Acknowledgment of Receipt of Materials <br /> Lu <br /> a Transporter 1 Pdntedffyped Name Signature Moynth Day ear <br /> a Transporter 2 Pdntedf typed Name SigiiturEF Month Day Year <br /> a <br /> r <br /> 17.Discrepancy <br /> 17a.Discrepancy Indication Space ❑Residue ❑Partial Re ❑Full Rejection <br /> ❑Quantity Type Rejection j <br /> Manifest Reference Number. <br /> 17b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> J <br /> U <br /> Facility's Phone: <br /> w 17c.Signature of Altemate Facility(or Generator) Month Day Year <br /> zz <br /> N <br /> 18.Designated Facility Owner or Operator.Certir+tion of receipt of materials covered by the manifest except as noted in Item 17a <br /> Printedrryped No e!' f SignatureMomn Day Year <br /> 169-BLC-0 5 11977(Rev 9/09) L f TRANSPORTER#1 <br /> tt <br />