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NON-HAZARDOUS 1•Generator ID Number 2.Page 1 of 3.Emergency Response Phone 4.Wa T kin Humber <br /> WASTE MANIFEST �] �PC (Eo Y0D a3p� ®� ���r <br /> 5.�� �ame a ail!g Address Hera s Si�dd�s{�e�gnt thanrnaiEi�address*}] <br /> I IfI n ■ J 'q.111L-2 X 2! <br /> Generator's aox- �1� �� I 7��� 6� �'�el A � �p j <br /> 6.Transpo l Oo n Na U.S.EPA ID Number <br /> i(A W7 &08k� <br /> 7.Transporter 2 company Name U.S.EPA ID Number <br /> B.Design d F cilityame adyte rid U.S.EPR Ifl Number <br /> Fact 's Phone: AV4 #U/s L* V gV'v 14�"r <br /> 9,Waste Shipping Name and Deseriptton 10.Containers 11.Total 12.Unit <br /> No. Type Quantity Wt Nal. <br /> 1. <br /> 2 <br /> W 2. <br /> t� <br /> 3. <br /> 4. <br /> 1 I Handling nstructi���� /49al Information ar�j��� 00. <br /> soi <br /> l5 1jr� <br /> holy 0+10 pajw 0zo <br /> 14.GENERATOR'SIOFFEROR'S CERTIFICATION:I hereby declare that the contents of this consignment are fully and Rcurately described above by the proper shipping name.and are classified.packaged, <br /> marked and labele placarded,and are in all respects in mr er condition for transport according to applicable intern nal and national jovernmental ygulations. <br /> Ge to t <br /> r tedlf p mrd Signature �f,]' M 7 <br /> 11011 <br /> 4// <br /> i15. ❑Intemallwal Shipments f �import to U.S. Ll Export from U.S. Port of entrylexB: <br /> Transporter Signature for exports onl : Date leaving U.S.: <br /> cc 16.Transporter Acknnwledgmenl of Receipt of Materiats <br /> LLI <br /> a TrXspr,f P�rintedfTyped NpDne Signature Ma Dgy Y�i <br /> ar <br /> r11 J�1F_ �U �• �]% <br /> a Transporter 2 PdntedlTyped Name Signature Month Day ar <br /> F <br /> 17.Discrepancy <br /> 17a.Discrepancy Indication Space ❑ <br /> Quantity ❑Type ❑Residue ❑Partial Rejection ❑Full Rejection <br /> Manifest Reference Number: <br /> 17b,Alternate Facility(or Generator) U.S.EPA I Number <br /> J <br /> L¢' Facillty's Phone: <br /> qW 17c.Signature of Alternate Facility(or Generator) Month Day Year <br /> 2 <br /> f.7 <br /> w <br /> v <br /> 18.Desigmted Facility Owner or Operator: receipt of materials covered by the manifest excepi a t in Item 17a <br /> PrintedrTyped Nameit <br /> re Y <br /> 169-BLC-0 5 11977(Rev.9109) DESIGNATED FACILITY TO GENERATOR <br />