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NON-HA7ARDOUS 1•Generator ID Nrsnber 2.Page 1 of ken*. <br /> nt Response Ptwna 4.Wagte;rac�g Num . <br /> WASTE MANIFEST - { <br /> 5.Geneialoi's Name and Malting Address s-Site Address(it different than maikgq address) <br /> ry:Transporter l Company Name q If 116.OfU.S.EPA ID Number <br /> 7.Transporter 2 Comp arae •• _ H15U.S.EPA ID Ntr <br /> .rt <br /> e.Designated Facility Nam,and Site-AddressENVIRONMENTAL U.S.EPA ID slumber <br /> TH DEPARTMENT <br /> 'fads Phone: <br /> 10.Containers 're V.:Total <br /> 9 Waste Shy Name and Description :.- <br /> No, <br /> Yype .. <br /> NO r <br /> t < xc <br /> Z <br /> 3 4. y pFtt N r <br /> �'. 4 � rh• YM � tYH�t� N J <br /> Y 7xfi f <br /> I&SW3Wdrut'InaWjctIons4nd6dcNonal Information <br /> Vol <br /> TJ <br /> 14.GENERATOR'SIOFFERM. IFICATION:I hereby declare that the contents of toes are fully and accurately described above by the proper shipping name,and are clasafred.Packaged. <br /> ma tabeled(pla 0 are in all respects in proper condition for transport according to kttertmf and r�tbrtad gove mental regulations. <br /> ors Pdntedrfyped Nana Month Di Year <br /> . "' �; "' �� <br /> ..r t5.I national Shipments w ❑Import to U.S. a Export from U.S.: 'r Pat of entry/exit <br /> -Transporter Signature for a Date leaving U.S.: <br /> 16,Transporter AcknaMedgment of Receipt of Materials <br /> Ic Transporter 1 Pdnted/fyped Narrro, rmtk� / ` �, �� Month Da Year, <br /> oro -Month Day >;Year <br /> zTransporter 2 Printedfryped Name "Signature <br /> 17.Discrepancy <br /> 17a Discrepancy Indication Space ❑moray ❑Type ❑Residua ❑p w Rejection El Full Retectron <br /> r Manifest Reference Numhar. .� <br /> 17b.Altercate Facility(or Generator) U.S.EPA IO Number <br /> u4 FaciWs Phone: <br /> 17c.Signature of Alternate Facility(a Generator) Month Day Year <br /> r <br /> 7A _ <br /> t1}.Designated Facilty Otmer or Operator.Certification of re Ma gf materWs covered by ifta maddest-e=W as rested in Item 17a <br /> Ptirtted/f Name Signature Month Day. Year. <br /> COPY <br /> 169-BLC-0 6 10498(Rev.9/09) <br />