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L 'i c , 4 ns� (:�(� <br /> NON-HAZARDOUS 1.Generator ID Number 2."age 1 of 3.Emergency Response Phone 4.Waste k ng rb <br /> WASTE MANIFEST y V 1 � D � <br /> - <br /> 5.Generator s Name and Mailing Address Generator's Site Address(if different than mailing address) <br /> I.- aora--j r7 -ELeje-j Sfoe tF <br /> P 0- 1 --(-i 5 U G?r] hq V I N C I �9- STD�k��rJ <br /> COOf <br /> Generator's Phone: <br /> 6.Transporter 1 ame � �] 1 U.S.EPA ID Num r <br /> 7.Transporter 2 Company Name U.S.EPA I Number <br /> S.Designated Facility Name and Site Address U.S.EPA ID Number <br /> Al W�i"TE (2�r1.i►u�-���S r <br /> CA CN5-SS <br /> Faci€i 's Phone: <br /> 9.Waste Shipping Name and Description 10.Containers 11,Total 12.Unit <br /> No, Type Quantity Wf.Nol. <br /> 1, <br /> 1V N� }467- WANG, 5OIG4;''�- (4,*DI o l kf <br /> IE <br /> x 2. <br /> to <br /> c7 <br /> 3. <br /> 4- <br /> 13.Special Handling instructions and Additional Information <br /> NO � �L L6 C7 <br /> 14.GENERATOR'SIOFFEROR'S CERTIFtCATIGN:I hereby declare that the contents of this consignment are fully and accuralely described above by the proper shipping name,and are classified,packaged. <br /> marked and labaledlplacarded,and are in all respects in proper condition for transport according to applicable fntsmational and national governments]regulations. <br /> Generator's/Offeror's"rintedlTyped Name Signature Month Day Year <br /> F�% 'O jvluc;- fk i CK M c(a <br /> F 15.International Shipments ❑Import to U.S. ❑Export from U.S. Port of entrylexlt: <br /> Transporter S oature for exports only): Date leaving U,S.: <br /> m 18.Transporter Acknowledgment of Receipt of Materials <br /> Transporter 1 PdntedlTyped Name Signa ra Month Day Year <br /> 4 Transporter 2 Printecryped Name Signature Month Day Year <br /> 17.Discrepancy <br /> 17a.Discrepancy Indication Space ❑Quantity ❑Type ❑Residue ❑Partial Rejection <br /> ❑Full Rejection <br /> Manifest Reference Number: <br /> 17b.Alternate Facility(of Generator) U.S.EPA ID Number <br /> U <br /> Facility's Phone: <br /> w 17c.Signature of Alternate Facility(or Generator) Month Day Year <br /> a <br /> a <br /> s� <br /> u: <br /> f] <br /> 18.Designated Facility Owner or Operator:Certification recei of mate is covered by the manifest except as noted in its 7a <br /> F[Printedlfyped Name Signature 0 ay r <br /> I <br /> 189-ELC-0 5 11977(Rev.9/09) DESIGNATED FACILE TO CH&dKANOR <br />