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NONHAZARDOUS 1.Generator ID Number 2.Page 1 of 9.Emergency Response Phone 4.Waste Tracking Number <br /> WASTE MANIFEST •g{ 1 / , Owl <br /> � <br /> �.. �a�d,a9 d�._ 4'S�iSi .:.Y r-? ota � �'�'Fti 1 i 'T f h:..f��' 1 �....x>�firT�:t'•.st� � <br /> 5.Generator's Name and Mailing Address J °Generatc?s Site Address(if different than mailing address) <br /> ���rlt t:��+��tJ / t�"l w,;`�aL•J;��it''::I� �fl i`�f.� s`r:•'t?' �9`�$r�,',.{4` JJ'' � ��,��• <br /> Generators Phone: <br /> 6,Transporter 1 Company Name / f U.S.EPA}ID Number <br /> 'S�'.d`r��!`'�,�. �/!r'J�...t �f.+''!"Y .�*��� f.:-�fa���,✓d?!t{f .�e'•>�°�`' . <br /> 7.Transporter 2 Company game U.S,EPA ID Number <br /> 8,Designated Facility Name and Site Address f r U.S.EPA ID Number <br /> ird <br /> Facility's Phone: <br /> 9.Waste Shipping Name and Description 10,Containers 11.Total, 12,Unit <br /> No, Type Quantity Wt.Nol. <br /> N 31 <br /> 13.,Special Handling Instructions and Additional Information ) '# y"u 1 ' <br /> r <br /> 14.GENERATOR'S/OFFEROR'S CERTIFICATION,I hereby declare that the contents of this 6onsignment are fully and accurately.described above by the proper shipping name,and are classified,packaged; <br /> marked and labeledtplacarded,and are in all respects in proper condition for transportaccording;to applicable international and pa tonal govemmehtal regulations. <br /> lvPrinted/Typed Name ))yy Signature ) pp• Month ,rpDaafy Year <br /> 15.International Shipmehts ❑Import to U,S, ❑Export from U,S+ Port oftentoxit�: _ <br /> Transporter Signature forex orts only): Daie lea'vin U.S,:'. <br /> cc 16.Transporter Acknowiedgmeht of Receipt ofy terials ; <br /> VTransporter 1 Prinied/Typed Name y.. Signature `d " '^^ k fAggth Day Year <br /> aTransporter2 Printedffyped Name ` ,✓ Signn`atare•-,., .; M " �' i�° " " Month Day Year <br /> t- <br /> 17.Discrepancy <br /> 17a.Discrepancy Indication Space <br /> ❑Quantity ❑Type 0 Residue ❑Partial Rejection ❑Full Rejection <br /> Manifest'Reference Number: <br /> ?� 17b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> J - <br /> U <br /> Facility's Phone: <br /> `a 17c.Signature of Alternate Facility(or Generator) Month Day Year <br /> z <br /> " <br /> 18.Design`atod FaciktyOwner <br /> or OperatorCertification ofreceipt of materiaiscovered by'the manifest except as`note'S'nIteiir 17a <br /> PrIntecirrypame <br /> Signature fytopth Day Year <br /> E <br /> TRANSPORTER <br /> 169-BLC-O 8'10498(Rev.9/09) #2 <br />