Laserfiche WebLink
— /L- 1 1 S -S lid <br />169-BLC-0 6 10498 (Rev. 9109) :;t .:,,"TED FACILITY TO GENERATOR <br />NON -HAZARDOUS <br />1. Generator IDumber n / <br />2. Paget of 3 Emergency Response Phone <br />4. Waste Tracking Number <br />WASTE MANIFEST <br />1[`� (l if <br />S <br />�a <br />5. Generators Name and Mailing Address J j) E� v` 'r0M r^ t Genera or's Site Address (A d fermi than mailing address) <br />/�- n f �. <br />T5S-7 Carwlo al <br />�gst_ s3o_ �ygy �'/'aCyr Ca. 9�3G y <br />41? <br />U.S. EPA ID Number <br />1 rAeooa�. <br />�31a <br />Tra'tsponer 2 Cor -pang Name <br />U S. EPA ID Number <br />-- <br />S. Designated Facility Name and Site Andress C , n C <br />UI S/ a!1 s PC-. n v ycl <br />U.S. EPA ID Number <br />W rSt #-1 zGr ave, <br />!k <br />ab .��s�/ g/� f /� C��ili0-!1 ca��bsa1 <br />nor. <br />9. Waste Shipping Name and Description <br />10. Containers <br />11 Total 12. Unit <br />� N0. <br />T Pe <br />OuanGy 1"JI-Vcl. <br />cc <br />' Exc rid,✓ CYG o- b 1a r �j <br />I <br />3 <br />o-�ttfs <br />6� o ap <br />L A rEA PAZ <br />. <br />wI <br />�� <br />zfoa� <br />P <br />-ate FAINT <br />3, <br />a. <br />13. Special Handing Instructions and Additional Information <br />3,X PO -114 s <br />3x eyd dons <br />14. GENERATOR'SJOFFEROR'S CERTIFICATION: I hereby declare that the contents of Nis consignment are f lti and accurately described above q' the proper snipping narre. and <br />are classified. packaged, <br />marked and labeled placarded. and are at all respects in proper conation for transport accordmg to applicable mtemationai and national governmental abons. <br />GeneratorsrOtferoi s Pnnied/TyprN Signature <br />Month Day Year <br />JC's-d k ✓a <br />'✓ <br />IGS 2 / <br />-J <br />'Z <br />15. International "pments <br />❑ Import to U S. ❑ Export from U Port of entry/exit: <br />Transporter Signature (lot exports only): Date leanng U.S.. <br />cc <br />16. Transporter Acknox4edgment of Receipt of Materials <br />Tr iter 1 Printed'Typed Name Sig a <br />Month Day Year <br />Z <br />Tran — <br />spoiler 2 Pnnted'iyped Name Signature <br />Month Day Year <br />F <br />( <br />17. Discrepancy — ---- -- <br />I <br />17a Discrepancy Indication Space <br />❑ Ouanbty ❑ Type ❑Residue <br />❑ Partial Rejection <br />❑Fun Rejection <br />Manifest Reference Number. <br />17b. Alternate Facility (or Generator) <br />U.S. EPA ID Number <br />U <br />t4i <br />Faoliry's Phone: <br />17c. Signature of Alternate Facility (or Generator) <br />Month Day Year <br />I <br />1— <br />N� <br />W <br />C <br />I& Designated Fao* Owner a Opetatoc Cerulhcation of -eceipt of material covered by Che rnarutest except as noted in Item 17a <br />Print�Syped Name S grhature <br />1... <br />Month Day Year <br />— /L- 1 1 S -S lid <br />169-BLC-0 6 10498 (Rev. 9109) :;t .:,,"TED FACILITY TO GENERATOR <br />