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NONHAZARDOUS 1.Generator ID Number, 2,Page 1 of 3,Emergency Response Phone 4.'Waste Tracking Number <br /> WASTE MANIFEST' 3y �� �� $ `: t <br /> 6,Generator s Name and Malting Ad ress ,,� 'Gene at r a Site Address(If different.than ailing address) µ <br /> Gerieratol s Phone: 7`` � " <br /> U,S EPA ID Number <br /> 6,Transporter1 Company Nam, , <br /> 7,Transporter 2 Company Name EPA ID Number, ' <br /> B.Designated Facility Name and Site Address U.S,EPAiD Nom6er <br /> �acili 's Phone: cr �l�'4.(rPc�P� �3Fjr3..� rti <br /> 10,Containers 11.Total 12,Unit <br /> 9,Waste Shipping Name and Description No. - Type Quantity Wt.Nol. <br /> r A �.�A vers.if ����{�5"�a;r fN- P0,,Sol0A4 5, � <br /> 0 � <br /> a c: <br /> 2. <br /> 3 <br /> n <br /> tttv4. <br /> 13,Special Handling Instructlohs and Additional rformation d <br /> 14,GENERATOR'S(OFFEROR'S CERTIFICATION:I hereby declare that the contents of this consignment are fully and accurately described above by the propershipping name,and,are'classified,packaged,, <br /> marked and labeled/piacarded,and are In all respects 16 proper condition for transport according to applicable International and national governmental regulations`,, <br /> Generatoes/Offeroes PrintedlTyped Name ._ $ Signature Month Day> Year <br /> a 15.International Shipments `f <br /> ❑Import to U.S. ❑Export frort4U,S; ,ort of entry/exih• ' <br /> Trans orter SI nature for exports only): / [� Date leavin U.S,: <br /> W <br /> 16,Transporter Ackrfowledgment'of Receipt of Materials 6f ti <br /> Transporter 1 P to ,yped Name • Sig t e Month, Day Year <br /> N Si natbre� ` Month Day Year <br /> a Transporter 2 Printed/ryped Name g• <br /> F <br /> 17.Discrepancy <br /> 17a.Discrepancy Indication Space R Quantity ❑Type ❑Residue EJ Pal lal Rejection 0F61 Rejection <br /> Manifest Reference Number: <br /> 17b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> U <br /> LL Facility's Phone: <br /> w 17c.Signature of Alternate Facility(or Generator) Month, Day .Year <br /> a : <br /> Z r a.'g ,.+•3t, W,�Cwx,. <br /> q8.Designated Facility Owner or Operator:Certification of receipt of materials covered by the manifest except as noted initem 17a <br /> Pdntedlryped Name Signature Month Day Year <br /> TRANSPORTER M <br /> 169•BLC-0 6 10498(Rev,9109) <br /> '° '%� ' <br />