Laserfiche WebLink
, 3 <br /> 1.Generator ID Number 2.Page 1l of 3 Emer body Response Phope ' C Waste Tracking Number <br /> NON-HAZARDOUS �}.� <br /> WASTE MANIFEST ,� ,�;,'evo, •�'" S <br /> Generato s Site'Address(if different than mailing address) <br /> 5.Generator's Name and•Maiiing Address <br /> Generator's Phone: U S EPA lD Number <br /> 6.TranspogLl Company Name �« <br /> �.�r;''"tr�k'f•�Qt ..'d,✓�•161.ri"S' .�.,t€. 'd.�'+}"';�:t:!„•`�r°(�'T�+7����. <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> r <br /> 8.Designated Facility Name and Site Address tf U txM1rrl`��.q,•gt,r't fir # U.S,EPA ID Number <br /> `t'iA(4i '6 raj• QalF�1 p<.. a"� i 9.,+?^� 7�.0 <br /> . `Facili 's Phone: <br /> • 10.Containers 11.Total 12,Unit <br /> 9,Waste Shipping.Name and;Description No. Type Quantity Wt.Nol. <br /> ..ti <br /> ** N <br /> tr <br /> Q i i tiar° p <br /> W k Y a iko' JvJ Y aJ�} ��fittaP L+' f <br /> 2. <br /> C� <br /> g* 3; , <br /> Pert. ':x•,+.7('.. .+. .r.. <br /> s and Additional info alio <br /> 5pec(al Handpng Instruction n <br /> y l 'f'i P 2 lr. �Z,}5 1. 7'��✓j'f !`!L f S {..r ;n w rf.�C,.1P $wP! 17 <br /> �,1, " r <br /> 14.GENERATOR'S/OFFEROR'S CtRTiFICATION Thereby declare that the-contents of this consignment are fully and accurately described above by the'propershipping name�and,pPe classified packaged,"r'11 <br /> 4 <br /> marked and Iabeled/placarded,add'are`In all respects in proper condition for transport'according toapplicable international and national;govemmental'regulation'. uhJ tit + r. <br /> Generator'slOfferor's Pnr ed/Typed Name�,w. Signature` ,r M�ntfi' r Day, t <br /> fv , <br /> e ' <br /> f `a 1 i�.' S,3 l.- .. •� '.� �,{• � �fd}tt'` Y z <br /> 15.International Shipments <br /> ❑I•'mport to U.S. ❑ExporHrom U.S. Port of entry/exit <br /> Transporter Signature for exports only)-. .' Date leavin U S,., <br /> cc 16.Transporter Acknowledgment of Receipt of Materials �'` <br /> W <br /> f ° { , Month Day Year. <br /> Transporter 1 P e yped N6 o Signature <br /> i � d�' D <br /> QTransporter 2 Pdnted/ryped Name + Signature Month Day 'Year.,' <br /> I 'F <br /> 17.Discrepancy <br /> 17a,Discrepancy Indication Space ❑Quantity ❑,Type ❑Residue r ❑PahiahReJection Ns2• a Fuli;Rejection <br />` Manifest Reference Number. <br /> 17b.Alternate Facility(or Generator): $i U.S.EPA`ID Number <br /> uQ. Facility s Phone; <br /> w 17c.Signature of Alternate Facility(or Generator) Morith Day Year <br /> C7 au ks-F' "�s" a <br /> Wr x <br /> r <br /> 18,Designated Facility Owner or Operator CertlllcatiQn of receipt;of matedals'icovered.byfhe manifest except asjnoted in Item 17a r F <br /> Pd6tedffypedN'ame r Signatdra �;' ° p� r �Month :�D�y <br /> CORY. <br /> 1169-11311-C-0 6 16496(Rev <br />