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i,Aj RIL S-'- <br />169-BLC-0 6 10498 (Rev. W09) TRANSPORTER M <br />lu"dN-HAZARDOUS <br />1. Gondar ID Numbv <br />2. Page 1 of <br />3. Emerpncy Response Phone <br />4. Waste Traaldng Number <br />WASTE [MANIFEST <br />S. Generators Name and Malting Address <br />' " A (d different than mabg <br />W1 QEiraiL LAiMS CaP *200 <br />tf tTf Iii T <br />STOO4TON.'C-A 9520T <br />164P A• HPUPOWA't' AVE <br />Generator's Phone:Tik <br />6. Transporter i Company Name <br />U.S. EPA 10 Number <br />t.�'i Tsp�irr Li.� <br />7. Tratlspotter2 Company Name <br />U.S. EPA ID Number <br />8. Designated Fadlity Name and Site AddressRt3 � <br />Rwokwft0426 <br />U.S. EPA ID Number <br />NWROW <br />CAIMXW 24 <br />VaGovi a. CA > 6MI <br />Pact]' s Phone: TOY -451-37M, <br />9. Waste Shipping Name and Description <br />10. Containers <br />11. Total <br />12 Unit <br />No. <br />Type <br />Ouantity <br />Wtivol. <br />1 i�c ►? �6 sIL <br />r,r <br />F <br />' <br />Q <br />Fes.. i <br />1�1i <br />c± <br />2 <br />Q <br />3. <br />4. <br />13. Special Handing InstrucMm and Additional Information <br />;f -; 71 4 <br />14. GENEFiATOR'SfOFFEROR'S CER11RCATION: I hereby declare that the contents of fids oonsignment are fully and accurately described above by the proper shipping name, and are classifled, packaged, <br />marked and labeledlplaa ded, and are in all respects in proper conditron for transpod <br />acoodng to appkable International and national governmental regWaflons. <br />GerwatarslOfierors PrbrtoOTyped Name <br />Signature - <br />Month Day Year <br />C t. <br />r <br />.A6a^PE <br />� <br />� <br />i5, intematlonaf Shipments . . <br />❑ inlportto U.S. <br />❑ Export from <br />�h— <br />Transooder Signature for exports onl : <br />16. Trwrwrtar AclalcAdgment of Receipt of Materials <br />U.S. Port of antrylaxtr <br />Date leaving U.S.: <br />Transporter 1 Prirdedliyped Mame <br />Signature <br />Momh 04 Year <br />Tfitsporfar 2 PrinWryped Hama <br />Signature <br />Morph Day lir <br />17. Discrepancy <br />17a. Discrepancy Indlegon Spam <br />❑ Quan6ly ❑Type <br />❑ Residue ❑ Pettlal fiejeciion <br />❑'Full <br />Manifest Reference Number: <br />17b. Alternate Facility (or Generator) <br />U.S. EPA ID Number <br />is <br />MR. <br />Faclifty's Phone: <br />W <br />17c. Signature of Alternate Fadflty (or GeneratM <br />Month nay Year <br />4 <br />sTi <br />tiJ <br />Cd <br />1$. Designated Fahy Oww or COMIator:-Cerdlrallon of receipt of materials covered by the manifest except as noted In them 17a <br />Pede fTyped Name <br />Sigr�ure <br />Month Day, Y <br />169-BLC-0 6 10498 (Rev. W09) TRANSPORTER M <br />