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<br />NON•HAZARDOUS
<br />WASTE MANIFEST
<br />I. Generator ID Number
<br />Ni/A
<br />2. Page 1 of
<br />1-
<br />3. Emergency Response Phone
<br />877,2364265-
<br />4. WeateTraCidniNurebor
<br />. .,1246029.5658.. 6 Generates Nerne•and Mailing Addrese -",
<br />'7 ' CiVivfiistStheictINIAInkip#UlgitiaS Df VIST011
<br />Generator's Pbenel ' :i,41747,
<br />- 'StOttbitOkI5206
<br />GenertItor'S Site Addidielft different !lien rnalfingliddrieej '
<br />6. TrCnsporter I CorreigIVRAr '
<br />Ant' --,‘
<br />U.S. EPA lp (looter
<br />' 1 1 t , -
<br />, 7. Tr000Perte2 Company Name U.S. EPA ID Number
<br />
<br />&Design-atm Facility Name end Site Address U.S. EPA ID Nufriber . .
<br />. .
<br />
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<br />.. Fitititis Poona: - .,,- i.-., , J! .:71tu4,...,:::: ..:gr: ....--
<br />' 31413174; ' ''' C ' :(7 ?,'.143001410:0
<br />9. Waste' ShIpteln; Nalneft0Peccileiron - -1O. coimooro it.Yaiii:
<br />44 6
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<br />. . . NO, Type
<br />•••Nol144otOoatWatte SoOdeelydrocarbon Impacted So - . := ... , i,- Y. ....1, •11 L :44
<br />.• •• 3% ;-.....0
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<br />Ia. Seel:hit Handling histnidions end Adrirdonal Information
<br />1 pittikkiii.22,62s, ,.
<br />-752603-4;., .$6.1,4v* /1- i. './ 12201*2.9,:
<br />4-- - ._ k Vck i
<br />Pc.' gENERATOE'S/OFFESOR'S CERTIFICATION: thereby declare NI the eante4e of tie consignmeat are hely and accurately des'cribed abyre the proper shipping name, and are ctaISItiedy packaged, .
<br />Ttnarked and labeled/placarded, and orate all respects InprOper cortdit)on for (rapport ne4oidlng to epplicahla International and national goiarratental regulations. _ , , Genifralealffekr'll Prielddifyped Name Signature ‘.. , kill) . ? pay Y.qar OOPS.
<br />—
<br />15 '. IntemOonal merits • Imrtrt io U.S. 0 iiiiiod from10. P.. oil of entry/ea'',
<br />Transporter Signature (for exports only): .Dale lemhifeit.S.: , TRANSPORTER 16. TransporterWowtedgeent of Receipt at ktatOrds
<br />Trannpojr 1 PrinteAped Nene Signature Month 4o.y . Year
<br />I (11-0-,i_ ,A--,?.".,- 7-.-- I -2 gul
<br />Trensporlei2 Printe *a Name
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<br />Sigooture Month ..;,pt - Yàr_
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<br />iii Diecrepaky
<br />17a. DiscrOportooig000k spot El i_i Ouanhly Ill Typo CI Residue El Pante! Reipcticn
<br />Manifest Reference Number:
<br />111 Fall Reloctic-n
<br />170. Alternate Facility (or 'Generator) US. EPA ID Number
<br />• Faillity's Phane:
<br />17c Signature of AllernaTeFecirty (or Generator) Month Dog Year:
<br />'. 111.Oes tallow Fattity Ovmer or operator Perecdon of receipt ot y sdbYelamenileateecereasnctecim tiers Tin
<br />PditteckTyped Naine Sigriture 111 ' 0
<br />I
<br />169-81.C-0 6 10498 (Rev. 9/09)
<br />TED FACILITY Tb GENERATOR
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