Laserfiche WebLink
169-BLC-0 6 10498 (Rev. 8/06) DESIG 4ATED*ettt� -GENERATOR <br />NONHAZARDOUS <br />1. Generator 1D Number <br />2. 2. Page 1 of <br />3 Emergency Response Phone 4. Waste Tracking Number <br />WASTE MANIFEST <br />CA k OC o 9-;L5-X 7 6 <br />! <br />S. Genera,or's flame arta Mailing Address Generators Site Address (A different than mailing address) <br />' £ R. 611/1r0%%/m,mfe-1 ..Inc:, <br />7 �,S) C o-r Mz /(C? �t �- <br />(✓/ <br />% o-cy COL, ISSN ! E G( <br />Generator's Phone! <br />6. Transporter Company Name U.S. EPA ID Number <br />K <br />i • Ell d : ;r c j1 A4f,A 'cj C .,-) 1c� (-'G'r;' <br />7. Transporter 2 Company Name U.S. EPA ID Number <br />8. De=nted Facility Name and Site Addressn U.S. EPA ID Number <br />Crt rforn,* Po-r,�tSr�eccly�c $nc. <br />, Y)-o 6c/a,4 Dr. fE• <br />Sc C ra-A,'-c^ 1,-) Cc.. (9/0 6r11- 700 <br />Facility's Phone: <br />9. Waste Shipping Name and Description <br />10. Containers <br />11. Total <br />Om" <br />12. Unit <br />WtNol. <br />NO. <br />TWO <br />¢ <br />ecy6l . rt. e er,'e- <br />0 <br />(Lg7EX PA Ani <br />3 <br />G F <br />2. C �. (It IEt� C y c l 1 i, ['An- <br />yGii <br />CLA7E <br />3. <br />13. Special Handling Instnrctions and Additional Information <br />14. GENERATOR'S CERTIRCATION: I certify the matenals descrbed above on this manAest are not srtject to federal regulations for reporting proper disposal of Hazardous Waste. <br />GeneratorsrOfferors Printed/Typed Name Signature Month Day Year <br />- �' �h S, l ✓��. �� -�, v is i <br />A <br />16. International Shipments <br />❑ Import to U.S. ❑ Export from U.S. Port of entry/exit: <br />Transoorter Signature (for exports only): Date lead U.S.: <br />¢ <br />w <br />16. Transporter Acknowledgment of Receipt of Natenals <br />t- <br />Transporter 1 Printedrryped Name S gnage Month Day Year <br />o <br />G <br />//n j �----' I s V S l <br />o 1 V1 i C L �--�; •- l� r n C lsl— <br />QTransporter <br />2 PrintedRyped Name / Signature Month Day Year <br />¢ <br />r- <br />17. Dzcrepancy <br />17a. Discrepancy Indication Space ❑ ❑ Type ype ❑Residue ❑Partial Rejection ❑Full Rejection <br />Manifest Reference Number: <br />} <br />J <br />17b. Alternate Fac&ty (or Generator) U.S. EPA ID Number <br />U <br />tai <br />Facility's Phone: <br />w <br />17c. Signature of A@emate Facility (or Generator; Month Day Year <br />Z <br />W <br />w <br />O <br />I <br />18. Designated Facility Owner or Operator. CertiFcatfon of receipt of materials covered by the manifest except as noted in Item 17a <br />P m yped Name �j Sgnatu / Month Day Year <br />169-BLC-0 6 10498 (Rev. 8/06) DESIG 4ATED*ettt� -GENERATOR <br />