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{ NON-HAZARDe?i1S 1.Generator ID Numtrer <br /> 2.Page F of Eme Re r � 4.Waste Tracking Number wasrl IaaNt sr --600 3.5 -x'5"7 1 � � ��� �p 4, <br /> 5.Generators Name and Marling Address r� Gene- s Site Address d differeni than i <br /> ao 11 <br /> �+(tt�r�1 �`;. {' nmSrg addressf Pv - <br /> 5 <br /> 64,,r y t 5 <br /> Generators Phone: -� <br /> 6.1 ranspo t Company Name -- <br /> U.S.EPA ID Number <br /> _ <br /> t3fc. rs{rtfY l�n�• <br /> 17.Transporter 2 Company Name -- _` <br /> U.S.EPA 1D Number <br /> 8,Designated FaGTdy Name and Site Address .�Ytr tt,sr ftr [ U,S.EPA 1D Number <br /> Fal Phone; r fJ <br /> 9.Waste Shipping Name and Description 14.Containers <br /> 11.Total 12 Unit <br /> -T No. Type Uuanftty WtNd. <br /> LLI <br /> o <br /> �2. <br /> q_ r <br /> ]3.5pedaE Han�utg'rutructlons end Addittonat 1r,4. +�ori <br /> ilii _ 14- 6SI i <br /> 14.Gt2NERATOR'St 7FHOR'5 CM FICATION,.I hereby dedare that the contents of tips Core are fly and acastata�desa�ed above <br /> marked and labeladlpfazarded,and are in ag respects in proper oondr 1 for transport accord toapplicableby the proper shipping name,ll are dassifed,.ra.-kVa <br /> Generator's10fferor's Prbi, Typed Name._ �W and national governmentaf mgu(a m- <br /> �l ahrre LUvrifi Ltis; <br /> a 15.Intema5onal5hipmerds <br /> ❑Import to U.S. � ❑ape't from T rer oue'far s Port ya <br /> ra 16.Tran*mr Ag=Wgdgment of,Receipt of Matedafs Date!es U.S.. — <br /> Traer 1I Typed Ny ne! +P — <br /> o Sgnatrne <br /> 1NCnttt Day Yrar <br /> C-1-7— <br /> Transporter <br /> _{ <br /> 2 Pdrafedffyped Name ' �i <br /> Signature " <br /> _ Month Day Year <br /> 17 Discrepancy <br /> 17L Discrepancy Indication Space <br /> L'4i�rff ty ❑Type ❑Residue 0 Partial <br /> RHckn �w�Fup'figjecfion <br /> i7b A!emate Far:ty to Gcrera=) Manifest Reference Number <br /> U.S i=PA ID Number <br /> CC <br /> ua. Fa6,,(s Phone- <br /> 17c 5ignamct.- <br /> re of Alternate Fa ; or G-wator) <br /> y I Month Day' Year <br /> Q�� <br /> 1 ti.pesignated Faa'tity Omer or Operator Cer:'.;ae,r of receipt of matedaEs coveredf the niedll s; �f fame — by manifest except as noted in"hem 17a <br /> S1 re. eat <br /> r _ Monts �y Y f <br /> 169-BLC-O 6 10498(Rev.9/09) <br /> COPY <br />