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't <br />t <br />z tu o <br />• <br />, <br />NON.HAzARDous <br />WASTE MANIFEST <br />I. Generator ID Number <br />N/A <br />g. Page .1 of <br />' ' 7 " <br />3. Emergency Response Phone <br />l'. 877-256.8265 <br />4.. Y'tgtk.t9 Tr0.4101,110b0f <br />- 2' 2941312 , <br /> <br />„ .. ,, , .. <br />*Generates Site Addlse frl dOleMolihOn Itatifteddni5s) , pai tilities Division - , U <br />-0152W <br />Generator's Phone: :: li:.19937.0870C, <br />5. TranSporter I Company Name <br />-POnclore*OprivrtolSevices . <br />U.S. gpa ID Number <br />-CAR000180737 <br />7..TranOelter 2 COrnparry Name U.S. EPA ID -Number <br />i <br /> <br />IL Po rla64E.eoliiitaucild Address . ,:o. <br />CA9.4585- ._ . • .-aciii shiane: <br />U.S. EPA ID Number , <br />24fr21 ...,.t.,,..': ';.: 1:4,14sakoolt:0104,0 _. <br />9. Waste:Shipping NaMe.pnd Desciplion 10. Contained I I. 'Nal . it.. ' <br />No. Type Quantity ' %%Aid <br />III 14pOtillairtipteS VISO) $03,910103011i20111, 11,1,10.10,10"Str ' 7-' ,111301,.t:'.•. <br />rz- •c• <br />2. . 4:.• 1. <br />• <br />t. ' <br />'1 <br />t : <br />t <br />:-. A <br />.A61611041.5044andAcitlilional information <br />..! }Air/246029 <br />... <br />.1kGENERATOR"WOFFEROWS CERTIFICATION:1 hereby dettlere that llitcontinifs of 151s consignment are fdly and accurately described above by .the proper shipping name, end ate Ossified, pa : .., ' inoof ar0 labelediplacardedend are In all reseed-sin Proper WOO, ter trariSikinaccording to anp5cabla international and nldonal governmental regideo,is. . ' • <br />G ralors/Olfemee Print ypediffanf b. <br />:..1. 15.1 =gorier Shipments II knort kilts. El EVoiffiVn a Port of entry'exiP <br />-.L.TransPerter ? , Senature (for evens only): Date ferivirxt U.S.: ., ..,... - ....•.. .7140ti2omell t 5. Tier:Spier Acknowledgment of Receipt of Materials , .... <br />Transporter t PrInletiffyped , ...,••=-' -.. Slikil(7.- ktilftill tit ' . . . .,......)",-, —1,4rc 17 , r 'Transporter 2 Printed/Typed Name _gn lure -Mehtfr Day Yø at -' <br />;- <br />. I <br />0 a sc. <br />0 <br />ri..411.cifiP?IncY <br />17;;;DIsCrejlEincy Ind:MINI SPact II atjantity 111 Type 0 Residue <br />ManIfeet Reference Number: <br />11 Partial Retention 11 . <br />-.> full-,R, .dm <br />17e, Attempt° Featly:(ar Generator) US. EPA 9) Number <br />FOY° Phone: <br />tic. Signaler° of Alternate Facility (Cr Generator) . Monte pay Var. <br />_ • . . <br />ig Designated FargthiThklief or Operator: C 1 materials covered by tho manifest ogapt as noted in Item t 7a <br />Printed/Typed Name Signature <br />I <br />I .P. Y <br />169-BLC-0 6 10498 (Rev. 9/09) <br /> <br />\--0141G1416ED FACILITY T G A