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NON.HAZARDOUS 1.Generator 1D Number 2.Page 1 of 3.Emergency se Phone 4,.VasteTracking Number <br /> WASTE MANIFEST <br /> 5.Generalo(s N e and Mailing ddress Generalor's Site Address[if different than mailing address] <br /> Gorato%Pho e: <br /> 6.Trans iter 1 Ca perry ame2 ` p U.S.EPA Id Number <br /> 7.Trans rte 2 Company Xme �lJ! U.S.EPA 16 Number <br /> B.D gna F 'lily N�eandpjta ddress,.—, U.S.EPA ID Number <br /> Facile aone *M <br /> 9.Wasle Shipping Name and Description 10.Containers 11.Total 12.Unit <br /> No. Type Quantity wtNoL <br /> 1. <br /> Cc <br /> CC CC �j - 2 SG f iA LfO <br /> 1` <br /> w <br /> z. <br /> 3. <br /> 4. <br /> L• <br /> 13.Special Handling Instructions and Add'i.,,31 information <br /> ��- <br /> o � <br /> 14.GEN ERATORVOFFERQR'S CERTIFICATION:I hereby declare that the contents of this Consignment are fully and accurately described above by the proper shipping name,and are ciassitiad,packaged, <br /> marked and labelealpfacarded,and are in all respects in proper condition for transport according to applicable international and national governmental regulations. <br /> Gen r' fero�c ri ed+Typad Na /1 ' Sig lure, � ' !O� 0 Year <br /> 15.In! agonal ShipmentsIn v <br /> Import to U.S. Export from U.S. Pon a ryle)A- <br /> z Transporter S' nature ifor ex orts only)! e 1 vi U.S.: <br /> w 16.Transporter Acknowledgment of Receipt of Materiats <br /> cc Transporter Printedi Typed Name / Signature <br /> � 4 -1 !h pay Year <br /> yr J <br /> Transpo er 2 Printeffyped Name Signal" <br /> Month Day Year <br /> a <br /> ti <br /> 17.Discrepancy <br /> 17a.Discrepancy Indication Space Quantity ❑Type ❑Residue ❑Partial Rejection ❑Full Rejection <br /> Manifest Reference Number: <br /> N 17b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> J <br /> CS <br /> 1Facility's Phone <br /> w 17c.Signature of Alternate facility(or Generator) Month Day Year <br /> a <br /> 2 <br /> i7 <br /> N <br /> 411 <br /> n <br /> 18.Designated Facility Owner or Operator;Cenifiealion of receipt of materials covered by the manifest except as noted in Item 17a <br /> Printed+Typed Name Signator th ear C�-�rW <br /> IP? <br /> 169-131-C-0 5 11977(Rev.9109) DESIGNATED FACILI TO GEN RATflR <br />