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I <br /> i <br /> NON-HAZARDOUS 1 1,Generator ID Number 2.Page 1 of 3.Emergency Response Phone 4.Waste Tracking Number <br /> WASTE MANIFEST 92:1-tjl;„-;'41, 0126:2.4 <br /> 5.Generator's Name and Mailing Address Generator's She Address(if different Than malling address) <br /> r +II=i:1G;4•{L'\';1'I•IT'1�r1L l'"ri,•�r••itJi?!:7r:'rlii'4�s�17 <br /> A,0Ji...G+AVE- <br /> ('A('A ✓9.520 <br /> Generator's Phone: �at3 4 t {,•1� <br /> 6.Transporter 1 Company Name U.S.EPA ID Number <br /> Er�11l1Rr?t�IPdE!•fI'?,4, tIJGl7't!S':� Cr\R000172•160 <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> 8.D1S11 •JW%90 f+'L;:u•'6'� U.S.EPA ID N <br /> a s•r4 , 5 a ��? :1PtFs. '1J+;u ,�Jrii�.J1FiI';1� umber <br /> •!•yG.l�ritAn•�T•Ss�Gkiadw0.b`��f`•Pr,'� r ""{y,Q1s1•�`1'rf�l:4:,1+�"' <br /> Il•4A,L:iC�h�ii\ J7ci iti4 La`;A' yJ r�� "y / A:Pa"4 d t+3 iV�3 ! <br /> i "iip =�5:yrf h A+tB"it `-G�tis r ,P'. .j if�a + dAwA"Ir <br /> Facility's Phone: y <br /> 10.Containers 11.Tota{ 12.Unit <br /> t <br /> 9.Waste Shipping Name and Description <br /> No. Type Quantity WI.N01. <br /> a <br /> 1. PI<:fil F0\ZARL-(AJS 1TI,r4;;TE��.)LIt7 1 :PJI Y <br /> 0 <br /> Iw <br /> UJ 2. <br /> (:3 <br /> i <br /> 3. <br /> 4. <br /> i ) <br /> i 13. Special Handling Instructions and Additional Information +� <br /> 013-1).i01L 100%UE I'-_L<481310 r-,PF%j! WEAIl AFriR.01 RIATE PPE IF1U:r VQr!.^Mi <br /> �,;1.4.6"� "'',.,,:ti.,. r��+��i;7'� 1�.rt t,1.'✓/A f{r•Y1 r::'�)�'at-� :5..,•rvo�f�T�6:.<,� <br /> 14.GENERATOR'S CERTIFICATION:I certily the materials described above on this manifest are not subject to federal regulations for reporting proper disposal of Hazardous Waste, <br /> Generatoes/QNeror's ii t yped Name Signature, �,.. � kJ (y r--� Month : Day Year <br /> 011 ,.) 4�v' �:t ,. <br /> 15.Intemational Shipments El ort to U.S.Im <br /> z p ❑Export from U.S. Port of entry/extt: <br /> Transporter SI nature for exports only): Date leaving U.S.: <br /> ee 16.Transporter Acknowledgment of Receipt of Materials <br /> Transporter 1 PrintediT ed Name <br /> e P YP Signature -� Month.- Day Year � <br /> #dj!c3-� aryaxr',nrq. r �.. :.ac'A } `�7-f, y,. •y , :;��':" ��" I_ `9 f f <br /> z Transporter 2 Printed/lWid Name Slgiiature r Month Day Year i <br /> 17.Discrepancy <br /> 17a.Discrepancy Indication Space r <br /> ❑Quanlity ❑Type ❑Residue ❑Partial Rejection ❑•Full Rejection <br /> I � i <br /> Manifest Reference Number: <br /> i 17b.Alternate Facility(or Generator) U.S.EPA 10 Number <br /> U <br /> rai Facility's Phone: <br /> 17c.Signature of Alternate Facility(or Generator) Month Day Year <br /> z <br /> z <br /> a <br /> w <br /> o <br /> 18.Designated Facility Owner or Operator:Certification of receipt of materials covered by,lhe manifest except as noted in Item 17a <br /> Prinled(Typed Name Signature 7 +• Month D <br /> 1 ay Ye <br /> ILLI <br /> +. l d r ) <br /> 1 \ 1' r j <br /> 169-BLC-0 5 11977(Rev.8/06) TRANSPORTER#-I <br /> t <br />