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UNIVERSAL 1. Generator ID Number 2. Page I of 3. Emerge Response Phone 4. Waste Tracking Number <br /> WASTE MANIFEST a` 1i :#'v%30 -530 h7t - d <br /> S. Generalofs Name and Mailing Address Densmore Site Address (if different than mailing address) <br /> T 1r6 T T. ..�ks�t i a a <br /> N1 CjArrxik 'kA%lf'irs : �ea�riy �xas� <br /> - :J `, . 'A FPJ!eed?# �, SIM ea "wo CA e}5r24Y,4 <br /> Genwators Phone: 016 2400 <br /> 6. Transporter 1 Company Name U.S. EPA ID Number <br /> 4�iS6JA�4` A10 TFk:aTdX4*arr :$ .i5¢-:sriiY22& v1Ad! climewi,,lum <br /> 7. Transporter 2 Company Name U.S. EPA ID Number <br /> a. D 5 0 < dti Na yl Site Address U.S. EPA ID Number <br /> +:k{�`.$sABYs'Ft34,$y "301 <br /> Fatlli (a Phone: $OiiAW-1U.4.a 4 <br /> 9. Waste Shipping Name and Desoripeon 10, Containers 11. Total 12. Unit <br /> - No. Type Quantity WINoI. <br /> 1 . .. s - ?F'sFax#l�.AS7e } 3 :9a 4i , fir, rtza'"u <br /> a <br /> � I <br /> w <br /> 3. <br /> 4. <br /> 13. Spedal Handling Instructions and Additional Information <br /> A, M-W C AMPT w lA f, ?$ffikYdT f ) _ _; 1' ° ttt, , j , 1 .. t \ , f :a•. 1 <. <br /> xutl tax y b$elsac TT*Vpor M avr. * r %aa r exp srt�ara}va s. 4th#L6@; y� t 1t 4tie4 ltit£6is <br /> A �. <br /> -WOO 33etdri. Tczxfnd X17 7T89 * � ;Tp$p;g ® 2iR>`Y V' ra <br /> 14, OENERATOR'$IOFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by the proper shipping name, and are dassded, packaged <br /> marked and labeledrplacarded, and are in all respects in proper condition for transport according to applicable International and national governments] regulations. <br /> GeneratorsrOflerors Pdnted?y ed Name Sig 51p ure Month Day Year <br /> - Irr\ i114/f � FEIVy CJ1 I Jai <br /> L 16. Inlemetbnel SNpments ❑ Import to U.S: ❑ Export from US. Pod of entryle>oC _ <br /> Transporter Signature for exports ori Date leevin U.S.: <br /> q i6. Transporter Acknoxgedgment ofAecelpt of Materials <br /> kL� Transpptler-i PdnitedRyped Name Signature I <br /> S _ J} >v kilrv- ,�.- Montt Day Year <br /> Transporter 2 PdnledfTyped Nemo Signature ' <br /> Month Day Year <br /> 17. Discrepancy - <br /> 17e. Discrepancy Indication Space ❑ Quantity ❑ Type ❑ Residue ❑ Partial Rejection <br /> ❑ Full Rejection <br /> ManAesl <br /> ? <br /> 17b. Alternate FaFacilityReference ly (or Generator) - Number. U.S. EPA ID Number <br /> 5U <br /> LL Faditys Phone: <br /> 17c. Signature of Allemales Facility (or Generator) <br /> Month Day Year <br /> z <br /> 0 <br /> 18. Designated Facility Oerer or Operator: Cer kation of recelpt of materials covered by the manilesl except as noled in Item 17a <br /> ii IYped Name Signature Month Day Year <br /> r_ eMcoernore 7 ewoocoe tnurrnr r•nov <br />