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J <br /> Please print or type.(Form designed for use on elite(12-pitch)typewriter.) <br /> NON-HAZARDOUS 1 1.Generator ID Number 2.Page I of 3.Emergency Response Phone 4.Waste Tracking Number <br /> WASTE MANIFEST <br /> Ft - ROD- 1 44P Y2A I liii <br /> 5.Generators Name and Mailing Address Generator's Site Address(if different than mailing address) <br /> ,I <br /> �vjw_+Ic�vq.f_.,cA) 1 P1 <br /> Generator's*Phone: <br /> 6.Transporter 1 Company Name U.S.EPA ID Number <br /> 7.Transporter 2 Company Name H(W HAZ,"ARIMS S 0W TIC44S,iWC U.S.EPA ID Number <br /> 8.Designated Facility Name and Site Address U.S.EPA ID Number <br /> GEM-PAF C'0R.00VA, <br /> I I as's VVKV E PKKJI�'P0. <br /> 142 <br /> Facility's Phone: <br /> ga. 9b.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 WtNol. <br /> 1. 1404 iH AZARMM WA <br /> 1150 P <br /> 0 F-PENT�.:AFGON <br /> Z 2. <br /> LU <br /> 0 <br /> 3. <br /> 4. <br /> 13.Special Handling Instructions and Additional Information <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 /> Generators/Offeror Pdntedrryped'Nqme Signature rte""a Month <br /> -Day Year <br /> T <br /> —1 15.International Shipments <br /> E]Import to U.S. ❑Export from U.S. Port of entrv/e'xil! <br /> Transporter signature(for exports only): Date leaving U.S.: <br /> LU 16.Transporter Acknowledgment of Receipt of Materials <br /> Transporte Printed/Typed N e Signature Month Day Year <br /> 0 <br /> CL <br /> U) <br /> Z Transporter 2 Printed/Typed Name Signature_ Month Day Year <br /> F_ <br /> 17.Discrepancy <br /> 17a.Discrepancy Indication Space ❑ Quantity E:]T'ype 1:1 Residue El Partial Rejection El Full Rejection <br /> Manifest Reference Number: <br /> 17b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> LL Facility's Phone: <br /> LLJ 17c.Signature of Alternate Facility(or Generator) Month Day Year <br /> L18.Designated Facility Owner or Operator.Certification of receipt of materials covered by the manffest except as noted in Item 17a <br /> Printed/Typed Name Signature Month Day Year <br /> 6-NHM-C-C-1 1 <br />