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-T� <br /> ti • <br /> lease print or type.(Form designed for use on elite(12-pitch)typewriter.) <br /> iNON-HAZARDOUS 1.Generator ID Number 2.Page 1 of 3.Emergency Response Phone 4.Waste Tracking Number <br /> . WASTE MANIFEST C;AI_fl(V ifi'H1 2w Ii2-6(i!(t <br /> 5.Generators Name and Mailing Adtlress Generators Site Address(if different than mailing address) <br /> I 0i PC N(i(:N7 fRiil.:F}W3 <br /> 11.0,W i HARTEP WA'r <br /> "10(.IJ NN CA 'a'•;h)fS <br /> Generators Phone: `O4..11513-51@21fy,- <br /> 6.Transporter 1 Company Name U.S.EPA ID Number <br /> :�f'ii1T''t1Ac'AF±D?:(i(11J iTk:0Y 1140 is yCt(itH�ralk7 6i <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> VsycabaF Iattfnlral1z,I_LE. PifL3ll.AlU3iKru <br /> 8.Designated Facility Name and Site Address U.S.EPA ID Number <br /> . c! i 1 a _ +tiDUUU73?':9kNr <br /> Facility's Phone: ' <br /> ga Sb.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit <br /> HM and Packing Group(if any)) No Type Quantity Wt./Vol. <br /> 1. fkN1VCi r At :+tai IL SI PA!(:A-11 1.1tGtP:,,4i 1 LIF <br /> :;,TSI v ,4_T J r/'JOEr <br /> Z 2. 1.fNV,1E &AL WA=TE,$TP,!V.NT I.Aki, 8FT GF <br /> HXxF1[2CTf PE01 ATCD <br /> 3. Y <br /> 4, <br /> �I I13.S7cial Handlin Instructions and Additional Information <br /> 14 <br /> 14. GENERATOR'S CERTIFICATION: I certily the materials described above on this manifest are not subject to federal regulations for reporting proper disposal of Hazardous Waste. <br /> Generators/OEerors PdntedlTyped Name Signature. Month Day Year <br /> j 15.International ShipmentsP <br /> f— ❑Import to U.S. ❑Export from U.S. Port of entrylexiC <br /> Transporter signature(for exports only): Date leaving U.S.: <br /> W 16.Transporter Acknowledgment of Reoaplof Materials <br /> Transporter1 nted1yped Nam <br /> �aj`.ry/ (i Signature Month�' D^ayy Year <br /> 4 Transporter 2 PrintedFryped Name Signature" Month Day Year <br /> 17,Discrepancy <br /> 17a.Discrepancy Indication Space ❑ Quantity Type ❑ 1e ❑ I <br /> ❑ El Residue Partial Rejection Full Rejection <br /> Manifest Reference Number. <br /> F 17b.Alternate Facility for Generator] U.S.EPA ID Number <br /> J_ <br /> V <br /> r¢i Facility's Phone: <br /> w 17c.Signature of Alternate Facility(or Generator) Month Day Year <br /> H <br /> Z <br /> 1 B.Designated Facility Owner or Operator:Cert'ficadon of receipt of materials covered by the manifest except as noted in Item 17a <br /> 1 Pnntedrfyped Name Signature Month Day Year <br /> 6-NHM44-11 <br /> 6-GENERATOR'S INITIAL COPY <br /> L <br />