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E 1 <br /> 4 <br /> 1.Generator ID Number 2:Page i of=Emergencyse Phone .4.Waste Tracking Number <br /> NON-HAZARDOUS WASTE MANIFESj <br /> Address r +' <br /> 'Generator's Site Address(if different than mailing address) <br /> 5.Generator's Name and Mailin <br /> fel 6c t.!4� '.f.: <br /> 4-�'1�Jzk�./�.�{.Jr�4 1..,:'�� � �?arr'✓d'.+Nzn Generators Phone: 4 <br /> 6.Transporter 1 Company Name U.S.EPA ID Number <br /> 7.Transporter 2 Company Name r 'U.S.EPA ID Number <br /> 8,Designated Facility Name and Site Address C U.S;EPA ID Number <br /> 7 r }f y /< f,j. " ,, 'i �aPk ti '3✓y p �' rw'ir�t <br /> kFaCIII s, hone: <br /> 10.Containers 11.Total 12,Unit <br /> 9.Waste Shipping Name and Description No. Type' Quantity Wt.Nol. <br /> cc <br /> } 1. !LLI <br /> /nBc � #re V1�{^•fir a fl. ^ rkT x <br /> cc <br /> 2. <br /> 13 Special Handling Instructions and Additional Information <br /> ij <br /> 14.GENERATOR'SIOFFEROR'S CERTIFICATION:I hereby declare that the contents of this consignment are fully and accurately described above by the proper shipping name,and are classified,packaged,. <br /> marked and labeled/placarded,and are in all respects in proper condition for transport according to applicable International and national governmental regulations. <br /> Generatoes/Offerors PrintedRyped Name Signatures Mont, Day Yens <br /> F 15,Intemational Shipments '`❑Import to U.S. ❑Export from U.S. Port of entry/exit: <br /> z <br /> Transporter SI nature for exports only): Date leaving U.S.: <br /> cc 16.Transporter Acknowledgment of Receipt of Materials <br /> Transporter 1 Pdntedhyped Name Signatures ! r Month Day Year <br /> ' /P' ?' <br /> N '' Y- + � t e / Signature ' Month Day Year., <br /> a Transporter 2 Printedffyped Name <br /> or <br /> H <br /> 17.Discrepancy <br /> 17a.Discrepancy Indication Space ❑Quantity ❑'TYPe ❑Residue D Partial Rejection ❑Full Rejection <br /> Manifest Reference Number <br /> 17b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> U pl. <br /> uu Facility's Phone: <br /> w 17c.Signature of Alternate Facility(or Generator) Month Day Year <br /> 18.Designated Facility Owner or Operator.Certification of recelpWf rriatedals covered by the mahifest except as noted in Item 17a <br /> Printed/Typed Namer Signature rj ^" Month Day Year <br /> � <br /> 169-BLC_C)"6.w 10COPY <br /> 498(Rev.9/09) <br />