Laserfiche WebLink
r: <br /> NON-HAZARDOUS 1.Generator Ip Number2 Rage 1 of 3.Emergency Response Phone 4.Waste Tracking Number <br /> WASTE MANIFEST ,•'�t+c,�t.�U�f��£� _7 �.�.•�� �7�:�_��i f` y - <br /> r <br /> i 5 Generators Name and Making Address /� T 'Gener'ator's Site Address(W ddiererrt than ma7ng address)6oO �* <br /> pp 0 <br /> r r f <br /> Generator's Phone M 3}w i R („, <br /> 5 Transporter 1 Company Name U.S.EPA ID NJumber <br /> 7 Transporter 2C°mpany Name U.S.EPA ID Number <br /> B.Designated Facr7ity Name and Ste Address U.S.EPA ID Number <br /> hone <br /> 9.Wasta Shipping Name and Description 10.Containers 11,Total 12.Unit <br /> ¢ 1 f NO. Type Ouantity WtNol. <br /> cs <br /> 13.Special HandEng En hZiions and Additional lntomraibn r <br /> 4 f <br /> f <br /> 14.GENERATOR'SIOFFEROR'S CERTIFICATION-1 hereby dedare that the contents of On cor*Vvnent are hrgy and accurate described above the <br /> marked and labeledrpW arded,and ere in all resperds in proper condi W for hansport aazrdN to appb=*y�ama and lafi,-w proper and name and are classdied peckayed, <br /> Generatoesweroes PdntedfTyped Name Qoverrvnentaf <br /> . 5igrrature`�' II Melrrfh Day Year <br /> 4•.i 15.lntematieonalShipments `- <br /> ❑Import to U.S. ❑Export from U.S. Port of entryfwdt <br /> Trar r 5' ature'far its ow: Data krarira U.S <br /> ¢ . <br /> 16.Transporter Ackwwledgment elf Receipt of Materials <br /> Traresfwrt�1 PtintedlTyped Name 5igrrature <br /> n. <br /> ,} � �' r Month day Year <br /> ca <br /> ¢ Transporter 2 PrintedlTyped Name J <br /> a k1B Month Day Year <br /> 17 Dissreparxy <br /> 17a.Discrepancy irrdwatlan Space <br /> ❑Ouantity LJ Type ❑residue ❑Partial Rejection ❑Full Rejection <br /> 17b Attemate Facility(or Generator) Manifest Relerence Number <br /> U.S.EPA ID Number <br /> G? <br /> Faaiys Phone: <br /> n 17c.5kjnatrre of AFemate Facffiq(or Generator) <br /> tx Month Day Year <br /> n <br /> 18.Designated Facility Owner or Operator-Cer6firatfat of receipt oI materials covered the manif - —' <br /> by est except as noted w Item 17a <br /> F Pdnteff ped Name f <br /> Month Day Year <br /> 169-BLC-O 0498(Rev.9/09) COPY <br />