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—_ <br /> L:.nlbt � I .:_ E <br /> ANIFEST <br /> rouN•HAURD�us � r I � r <br /> t WASTE M ' .p ' <br /> v Generator's Nameand MailirgAdd;<s� P otor,.itrAiares„n dieeentriar me krp addr <br /> i <br /> 1 <br /> a i {venerators Phone `. <br /> 6.l'ransporter t Company Name U.S.EPA ID Number <br /> ff 1 <br /> 7.Transporter2 Company Name 1 LS EPA ID Numbor <br /> 1 <br /> 8.Designated Facility Name and Site Address if t A p 1- U.S.EPA IU Number <br /> 7�5w iR1Y F+.1 crx <br /> i16 Facildy's Phone: <br /> 9a 91p U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers I 11.Total 12.Unit <br /> HM and Packing Group(if any)) No Type Quantity WI/Val. <br /> L <br /> 2 2. <br /> W <br /> f'J <br /> 3. <br /> 4. <br /> 13.Special Handling Instructions and Additional intonation <br /> FfACTHI )ttd(>4?1t6L(}i,ef*`[:iT�1C-#Sf$d1`t"y` <br /> 14. GENERATOR'S CERTIFICATION: I codify the materials described above on this manifest are not subject to federal regulations for reporting proper disposal of Hazardous Waste. <br /> Generator's/OHeror'sPrintedRyped Name _ - Signature f Month Day Year <br /> J t 6.International Shipments <br /> F-- ❑Impod to U.S. ❑Expert from U.S. Port of entry/exit <br /> Z Transporter signature(for exports only): Date leaving U.S.: <br /> w 16.Transporter Acknowledgment of Receipt of Materials <br /> Transporter l PolardlTyped Name y Signature ' $ Month Day Year <br /> zQ TransporterRPrinted/Typed Name Signature Month .x Day tEaf <br /> C <br /> i'/.Discrepancy <br /> 17z.Discrepancy Indication.Space <br /> 1 ❑ Quantity ❑Type ❑Residue ❑Partial Rejection ❑FW Rejection <br /> s Manifest Reference Number <br /> � 171h.Alternate Facility(or Generator) U.S.EPA ID Number <br /> J <br /> U <br /> ua. facility's Phone: <br /> 17c:Signature ofAdernate Facility(or Generator) Month Day Year <br /> r_ <br /> Z <br /> C7 <br /> w <br /> w <br /> O <br /> 18.Designated Facility Owner or Operator:Certification of receipt of materials covered by the manifest except as noted in Item 17a <br /> Pdnted/Typed Name Signature Month Day Year <br /> 6-NHN,-GC-11 <br /> 6-GENERATOR'S IN!T fAL COPY <br />