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tY <br />0 <br />a <br />Q <br />tL <br />Z <br />w <br />a <br />NON -HAZARDOUS 1. Generator ID Number <br />WASTE MANIFEST 11A) ' APPUGA�1Li: <br />5. Generator's Name and Mailing Address / / <br />t.rl�a�5'C, c.� 4it,;t�fJct�s �.cDVr�7�'� t <br />b 7S i2e1 Gd <br />Generators Phone: '7,7 —J — / — <br />6. Transporter 1 Company Name <br />1,11). J 1n <br />7. Transporter 2 Company Name <br />8. Designated Facility Name and Site Address <br />S426 HAY ROAD.. VA.GXVI L- E, (".A 95587 <br />Facilitv'c Phnn, 17071 AMA—r 1 is <br />2. Page 1 of 1 3. Emergency Response Zone, r 4. Waste Tracking Number ;M. <br />873 <br />Generator's Site Address (if different than mailing address) <br />V2 J <br />U.S. EPA ID Number <br />NOTAPPLIGMLE <br />U.S. EPA ID Number <br />U.S. EPA ID Number <br />NOT APPLICABLE <br />9. Waste Shipping Name and Description <br />10. Containers <br />11. Total <br />Quantity <br />12. Unit <br />Wt.Nol. <br />No. <br />Type <br />Signature /1 <br />q ) <br />..F L..d <br />–t- <br />15. <br />15. International Shipments <br />❑ Import to U.S. <br />❑ <br />Export from U.S, Port of entry/exit <br />2. <br />Transporter Signature for exports only): <br />Date leaving U.S.: <br />t2 16. Transporter Acknowledgment of Receipt of Materials <br />F <br />3. <br />Transporter 1 PfntIdlTyped Name <br />1 'r r <br />Signature / <br />� � � <br />Month Day Year <br />Z <br />I <br />11 C-W <br />4. <br />t <br />Transporter 2 Printed/Typed Name <br />Signature <br />Month Day Year <br />Manifest <br />17b. Altemate Facility (or Generator) <br />i <br />Facility's Phone: <br />17c. Signature of Alternate Facility (or Generator) <br />i <br />U.S. EPA ID Number <br />Month Day Year <br />tPdnttcjypecI <br />8. Designated Facility Owner or Operator: Certification of receipt of materials covered by the manifest except as noted in Item 17a , <br />Name ,i Signature Month Day Year <br />41 <br />9 -BLS -C 5 11979 (Rev. 9/09) �= ' �� TRANSPORTER #1 <br />A <br />14. GENERATOR'S/OFFEROR'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 <br />condition for transport according to applicable international and national governmental regulations. <br />Generato's/Offeror's Printed/Typed Name <br />Signature /1 <br />Month Day Year <br />–t- <br />15. <br />15. International Shipments <br />❑ Import to U.S. <br />❑ <br />Export from U.S, Port of entry/exit <br />Transporter Signature for exports only): <br />Date leaving U.S.: <br />t2 16. Transporter Acknowledgment of Receipt of Materials <br />Transporter 1 PfntIdlTyped Name <br />1 'r r <br />Signature / <br />� � � <br />Month Day Year <br />Z <br />t <br />Transporter 2 Printed/Typed Name <br />Signature <br />Month Day Year <br />repancycrepancy <br />Indication Space <br />❑ Quantity <br />ff <br />❑ Type ❑ Residue ❑ Partial Rejection <br />1 <br />El Full Rejection <br />Manifest <br />17b. Altemate Facility (or Generator) <br />i <br />Facility's Phone: <br />17c. Signature of Alternate Facility (or Generator) <br />i <br />U.S. EPA ID Number <br />Month Day Year <br />tPdnttcjypecI <br />8. Designated Facility Owner or Operator: Certification of receipt of materials covered by the manifest except as noted in Item 17a , <br />Name ,i Signature Month Day Year <br />41 <br />9 -BLS -C 5 11979 (Rev. 9/09) �= ' �� TRANSPORTER #1 <br />A <br />