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I <br /> Or <br /> Please a+int or type <br /> Farm dasi reed inr use on ellte,I12•0ch _wr -_ -• <br /> I ! , Generatar ID Number <br /> NON-HAZARDOUS 2. Page of 3. Emergency Response Phone 4. Waste Tracking Number <br /> WASTE MANIFEST C �IC420 3� � � Z � � FW 577 174 <br /> r <br /> 5. Generator' Nam a aiti fires generators Site Address (�f different than mailing address) <br /> i Lit a r5 F37j & 2A2a <br /> 7te <br /> � A R 3�?� � 1 raw.c CR <br /> Generator's Phone: ` �► <br /> � 6. Transfrqr 1 Cam ny Name U.S, EPA ID Number <br /> fqrtf <br /> Virg?OM4,0C sty V 6C, 5 C t4 9 00310o03 <br /> 7, Transporter 2 Company Name U.S. ERA IQ Number <br /> 8. sign te Facility r�p.and�ite Add �� U.S, EPA ID Number <br /> 247 31 .11 �3� <br /> Q 1 <br /> � t � <br /> Facility's Phone. <br /> TO_ Containers 11 . Total 12. Unit <br /> 9. Waste Shipping Name and Description <br /> No. Type Quantity Wt.NoL <br /> 0 <br /> ( SOL [ LKA. wa hj <br /> Sj IV[ bL <br /> W 12. <br /> L7 <br /> 3. <br /> 4. - <br /> 13. Special Handling Instructions and Additional Information <br /> 0 <br /> 14. GENERATOR'S CERTIFICATION: I certify the materials described above on this manifest are not subject to federal regulations for reporting proper disposal of Hazardous Waste. <br /> GeneratoeslOifernr's PnntedfTyped Name Signature Month Day Year <br /> � a rn ra 60, r7 " r E �� A <br /> _j 15. International Shipments i�1 <br /> � u Import to U.S. Export from U.S. Post of entrylaxitq <br /> � Transporter Signature for exports only)-. Date leaving U.S.: <br /> � 15. Transporter Acknowledgment of Receipt of Materials <br /> � Transporter 1 PrinteVyped Name Signature Month Day Year <br /> o� <br /> t � Tr nsporter 2 PrintedlTyped Name Signature <br /> Month Day Year <br /> d <br /> cc <br /> 17. Discrepancy <br /> 17a, Discrepancy Indication Space <br /> Quantity ❑ Type ❑ Residue D Partial Rejection ❑ Full Rejection <br /> Manifest Reference Number: <br /> 17b. Altemafe Facility (or Generators U.S. EPA ID Number <br /> 3 <br /> u. <br /> Facility's Phone' <br /> 13 17c. Signature of Aftemate Facility (or Generator) Month Day Year <br /> a <br /> z <br /> t� <br /> W <br /> 18. Designated Facility Owner or Operator. Cefficalion of receipt of materials covered by the manifest except as noted in Item 17a <br /> � Printed/Typed Name r Signature h a r <br /> VA k7 & <br /> � Printed in USA by GC Labels -, r ar## MANi �'100800-997-6966 DESIGNATED FACILITY TO GENERATOR <br /> 913-897-6966 <br />