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<br />NON.HAZARDQUS
<br />WASTE MANIFEST
<br />1. Gene/afar ID Nymber
<br />N/A , • •
<br />2. Page I of
<br />1
<br />3. E _ &,Response Phone
<br />- 77-256-8265
<br />4, Waste Tracking Number -22-260294005Y -
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<br />A • , .. • • t • t l -ISIS:ix Diviefola Generator's SIMIAdthess Of different than Mating addrota) ., . Nu',re • 1., •47 a p
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<br />Generator's Phone: -: '2/3979.37.47a° • ". 2
<br />A. Tra2porter 1 OpinpvMame _ . bf.S. EpA H-4 Nerebet '.:,:.:I rOngeWirgirotiMarni,Seniket.. , 1.4)- 1,:, ;.':oa, .,,- '.I... -;•-4441104.40 AO 73 i ' .1*
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<br />9. Matra S_SPOIng Name ON Descriptors 10, DenIalnera II. Total 12. Unli
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<br />)0422281
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<br />GENEAATOR'S/OFFEROR'S CERTIFICATION: thereby declare that the contents of this consignment are fully and accurately described above by the proper shipping rianiei.end are illassified, packaged, :
<br />I marked and labeled/placarded, and are in all respects In proper crinditIon for transport according to applIcab'a international and national governmental repletion&
<br />Generators/Offerors AMMO/Typed Name Signature ''Xiirdli • .* -11. • .
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<br />lfrspoll to Q.t. 111 Export 161n U.S. PON entrykodt: • Transporter Signature Nor exports ettlyti baiititavng U.S:
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<br />16.TraiiiPtiitgAnkiSMidadgrirentof Ai:0440 MsOrials
<br />Transporter I Printadrryeed frame Signaittib
<br />IN ) I LA,IA m till e-itk Pi PA I
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<br />Transporter 2 Printed/Typed Narita • TsicetelP3
<br />I !MMIMIIMMMMMIMMI bE,SIGNATED FACILITY 47. Dikripandy .:
<br />01Screpancy Indication Space 1----1 1._.1 Quantity Djpo 121 Residue
<br />Manifest Reference Number:
<br />111 Partial Ref oder) 6;9 Dite4iefi' '
<br />Alternate Facildy (or Generator) US. EPA 10 Number
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<br />FaciEly's Phone:
<br />17c. Signature of Allernale Facility (or Generator) MOtith bay War
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<br />18. Designated Facility Owner or, Operator refication o eip et maceriais covered by the manifest except noted In Item 17a \ r
<br />Printed/Typed Name Signet(' M a
<br />WA
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<br />169-13LC-0 6 10498 (Rev. 9/09)
<br />
<br />DESIGNATED FACILITY T GMPIATOR
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