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NON-HAZARDOUS a,1,Generator ID Number 2.Page I ol Emergency Response Phone 4.Waste Tracking Number <br /> WASTE MANIFEST <br /> 5.Generators Name and Mailing Address Generators Site Address(if different Than matting address) <br /> iRkCy.GA 33 14 frk 0 <br /> Genamtors Phone: <br /> *4)_Company Name U.S,EPA D Number <br /> 7Tmnspode <br /> -u'Pe."N <br /> U.S:EPA ID Number <br /> Z <br /> 8,Dessihnifteel'al NameardtfifeAddimes U.s,LVA U)Nuffi <br /> foofoal wavle StAllorr's H.4 R994 1.arnit <br /> x•425 Hay Ra <br /> 13431IIIQ.C". 99657 USA <br /> Fall 'e Phone: 70,1.437-1r.74 <br /> 10.Containers 11.Total 12.601h <br /> 9.Waste Shipping Name and Description No. Type Qual <br /> 1 -14 H.4ZAftoojjl;WAS-ir Sl f90l �Vrrh TRACE 20 <br /> o , <br /> DROCARI <br /> z 2. <br /> 3. <br /> 4 <br /> 13Special-HnndI6nglnst%4 Juna Actifiloral Information <br /> 14.GENERATOR'S/OFFEROR'S CERTIFICATION:I hereby declare that the contents of this consignment are fully and accurately descirt, boys by the proper shipping marl and are classified,packaged. <br /> martial labeled/Placarded,and are in all respects In proper condition for transport ackel to.applicable international and national ginAunringntal regulations. <br /> lfiarors7edl Name' bi Mon,h Day Year. <br /> 15.Ince'ed nal Shipments <br /> El El <br /> wmi to U.S. ExponfromUS. Pon of entry/exit: <br /> Trans; der s nature(for exports orl Date leaving U.S.: <br /> w 16.Transporter Acknowledgment of Rocalict of Materials <br /> --- M tal 0 Year <br /> cc Transporter I Printedi Name <br /> 0 -1 <br /> -Signature Day Year <br /> z Transporl Pfirted/Typed Name <br /> 17 Discrepancy <br /> 178.Discrepancy Indication Space ❑ <br /> QuantityEl Type ❑Residue El.Panel Rejection El Full Rejection <br /> --Mani(estReleremi <br /> 17b.Alternate Fal(or Generator) U.S.EPA 11)Numb., <br /> Xg Facticys Phone: Month D Year <br /> 17c.Signature of Alternate Faculty(or Generator) <br /> 18.Designated Facility Omer or Operator Certification of receipt of materials covered by the marl except at;noted in Item 17a <br /> Puntedi Name Signature Month Day Year <br /> f <br /> DESIGNATED FACILITY'S C PY <br /> 169-BLC-0 5 11977(Rev.9/09) <br />