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1.Generator ID Number 2.Ps e 1 of :.Emeigancy Response Phone A.We to Tr a,kl�p um r ;'l <br /> p <br /> WASTE MANIFEST, C�?�..oc 3' f .''. •. peneretdre 31te:Adtlress ptOilterentthan mailing address). <br /> 5.Generator's Neme.and'Malling Addresw. <br /> s. <br /> )CfG (" <br /> neratOte'Phona: U�:3:E:P�A I��f/Number <br /> / <br /> 6,Transport '1 Company Name " + �`+•K ,lam�`y 7 Uf ' <br /> PA.ID Null <br /> nine <br /> .7,Treneporter2 <br /> Comp .Y . , • <br /> PA Ib umber <br /> a• s <br /> .U.S.E N ;. <br /> g:Designated Fadliry Name•egd'Slla Adis l� '•' G�.rGt f�, c- <br /> adii •s Phone: tokcoritainers i 1,Tole). 12.Unit <br /> No. ;.T' a Quantity:. WtNot, <br /> 9.Waste Shipping Name and Descdpdon e <br /> 'a ;��,. 1•.t�nldCc'f�'[i- �fp§ 1 ;�?r�,y�$ ( �,�t!1 �� � � I <br /> AWS tJ f' I t <br /> F <br /> 13,s aclaiHanding I i uclbns andAdditionalrm <br /> infoation Vd r rvi:4 Sjp=r t 'js <br /> riAl <br /> �y..., . <br /> 14,GE NERATOA'SIOFFEROR'S CERTIFICATION: -hereby dal fa efcont ��tthis��ing to applacafileIfui11 lnrind lema!Ioriai and national go6emr Iove by regulatinippingname;and are ciassitied,.packagedYe�, <br /> marked and Iabeled/p4acArded,'andare In respects in prop 4 Signa11 11 ture ' . M�th Day <br /> �' _ <br /> :Generate <br /> lamraPdntedlfypedNanre t ^� 'Y-1 '-^^ r <br /> '` : ;__.� ,>'rix .:• � • . <br /> f emrylexil: <br /> 15,Intematlonai'Shipments:: impodto�U,S,', Expod Irorp U:S, part-of. <br /> •. •Deleleavin I U.S.: • <br /> Tions odel-SI nature.iffor-expoltiol <br /> a f6.Tfanspoper Admovrledgmerd of Receipt of Materials 5lgnalure l , M th Day Y"ear• <br /> ' Trenspo PP��ptadlLyped Na <br /> I �p <br /> • Month Day Year <br /> AA; <br /> v7 ed Name. r Signature <br /> TranspprleT 2 Plnledlfyp <br /> 17:DiscrepancyQ Partial ReIsctlon- e LJ Full flejection ' <br /> 17a:0lscrepency.Indication Space Quantity <br /> LTyps. ~... O Reeltluo'. <br /> f-J <br /> Manttesl'Reference Number. U.S.EPA ID Number <br /> 17b.-NiQmate Facility(or Generator) <br /> Month Day Year <br /> u. Facllitlls Phone:. <br /> . 170.Sigriatura of Alternate Facility(or Generator) <br /> � a;d f- �,i"•'" .s y-, ,�7, � i�• ''i� n P� �'' _� y�P �� F�w 4.tv�",�J' , <br /> 18,Deslgnaled Facility Owner or Operator.CeHigcallon o1 receipt of matelots covered by the manifest except es noted In item 17a , + Mogth Qqy. Y,e1. <br /> Slgnaiure' f1 ' �•••f � <br /> Pdnle a "+ /' i• /i /r ,: <br /> dlCyPad,7I.'f j! � TRANSPORTER#? <br /> s 169-BLO.0 6 10498(Rev.9109) <br /> E <br />{ <br />{ <br /> I <br />