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NON-HAZARDOUS I Gene tD Number 2.Page 1 of A- 3.Emerge R Ph e 4 Wast�kjpg I�'j <br /> WASTE MANIFEST VVff11 <br /> 5.Gena=r s1Va�nnaiiing ddress Generators Site A re �V <br /> 72011) <br /> © �jj�1 �I�!—1 <br /> Gene ft.;'P'4:'dxj f/V lIi{I D <br /> 6-Transport r 1 Na 1 r ® ®, U-S-EPA ID Number <br /> 7-Transporter 2 Company Name li U.S.EPA ID Numberr�ifd <br /> 6-Des net N and 5' re s • U-S.EPA ID Number <br /> 6 h41git � <br /> I�/1I7�!//7�I11 �Facili 's Ph : 1r"�!"r+ <br /> 9.Waste Shipping Name and Descdption 10-Containers 11.Total 12.Unit <br /> No. Type ❑uantfty WI-Nal. <br /> 1. <br /> M ljdl� <br /> W <br /> a 2 <br /> W . <br /> f7 <br /> 3. <br /> 4. <br /> 13.Special Haling Instructions and Addie�I Irdorrnation <br /> So I n <br /> q�- lod 7� <br /> iI t4c Dr/ D'6 <br /> 14.GENERATOR'SfOFFEROR'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 fabeleTiplacarded,and are in all respects in proper condition for transport according to applicable international and n tional governmental regulations. <br /> Gen ❑ ercr' 'tedlTy em Signa r �e7 � A ` , }� Mo Day Year <br /> J 15.Intemational Shipments ■�lI (f �I•/Jrl`/Jr/J� <br /> import to U.S. Export Pram U.S. Port of entrylexit: <br /> Transporter Signature for exports only): Date leaving U.S.: <br /> 16.Transporter Acknowledgment of Receipt of Materials <br /> T r 1 PrintEdITM Name f Sign Mon Day ea�7 g4-11 ( <br /> 75 <br /> a, V)&�7 J <br /> Q Transporter Pdnted7yped Name Signature Month Day Year <br /> x <br /> F <br /> 17.Discrepancy <br /> 17a.Discrepancy Indication Space <br /> ❑Quantity ❑Type ❑Rasfdue 11 Partial Rejection ❑Ful!Rejection <br /> Manilesl Reference Number: <br /> 17b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> J <br /> Facility's Phone: <br /> 17c.Signature of Altemale Facilhy(or Generator) Month Day Year <br /> a <br /> z <br /> c� <br /> N <br /> W <br /> O ' <br /> 18,Designated Facility Owner or Operator:Certification of t of materials covered by the manifest except as otet in item 17a <br /> PrintecVTyped Name Sig t e M <br /> 169-BLC-0 5 11977(Rev.9/09) DESIGNATED FACILITY0` <br /> GENERATOR <br />