|
NONHAZARDOUS 1 Generator ID Number 2.Page 1 of 3.Emergency Response Phone 4,Waste Tracking Number
<br /> n
<br /> WASTE MANIFEST e'Z41 4f4p—f.. �;v�G� ""'da flea� � .`; � i ��f
<br /> 5,Generator's Name and Mailing Address"' i v r j `2 / 'Gene ator's Site Address(if different than ailing address)
<br /> ` • ]1.f � s� "7 4;7� ���'� " � � r � '� � � ���r!'.} y1 I{;:.�, �ai�`r'� rtn.�'
<br /> dYaf., la
<br /> Generator's Phone,
<br /> 6,Transporter 1 Company Nam2 }} _ U.S:EPAIDNumbers y 9
<br /> i�a k'�31'S'�l F.° f'��,�,,)�rJ J.,./ �^*'f'lt", �a:4f Ol•t;��w'�rratr.�r..:•d•yr,d G',+��'��j'�.
<br /> 7.Transporter 2 Company Name U.S.EPA ID Number
<br /> 8.Designated Facility Name and Site Address tr,y r. U,S,EPA ID Number
<br /> c
<br /> r v
<br /> faoili 's Phone: �.r�r G I. .h{'. IL: f., '1 ur J a,'-.1� "° t, r• r'}l t!'
<br /> 9.Waste Shipping Name and Description 10.Containers 11.Total 12.Unit
<br /> No. Type Quantity Wt.Nol.
<br /> � ,�•1. (�/Ll i t.t'ivr�jtY t fi�;•�(�y'�..+,':i t"'i` ;'.�r ..`,')r.?�.
<br /> a om
<br /> w
<br /> W k f 2,
<br /> 3,
<br /> r
<br /> 4, E
<br /> ;x
<br /> 13.Special Handling Instructions and Additional I formation
<br /> 14,GENERATOR'S/OFFEROR'S CERTIFICATION:I hereby declare that the contents of this consignment are fully and accurately described above by the proper shipping name,andarecla$siffed,packaged,
<br /> marked and lab eled/placarded,and are in all respects in proper condition for transport according to applicable International and national governmental regulations`,,
<br /> Generatoes/Offeroes Printed/Typed Name ._ Signature Month Day` Year
<br /> r ,
<br /> 15.International Shipments
<br /> ❑ r � m�•.
<br /> Import to us, Export from UM:,-
<br /> ,S: Po�rt of entry/exit:
<br /> Transporter Signature for exports only): Date leavin U.S.:
<br /> cc 16.Transporter Acknowledgment of Receipt of Materials
<br /> <'
<br /> Transporter 1 P�Hnted/fTYped Name , t Sig atif e , �" Month Dray Year
<br /> C Transporter 2 PdntedlTyped Name Signatbre Month Day Year
<br /> F
<br /> 17.Discrepancy
<br /> 17a.Discrepancy Indication Space
<br /> ❑Quantity ❑Type ❑Residue El Partial Rejection ❑Full Rejection
<br /> Manifest Reference Number,
<br /> ? 17b.Alternate Facility(or Generator) U.S,EPA ID Number
<br /> C.J
<br /> V
<br /> W Facility's Phone:
<br /> w 17c.Signature of Alternate Facility(or Generator) Month Day Year
<br /> a
<br /> z
<br /> ,�. g,;F � �,��at j�� �. �,ter :'.;;t a it�,�+ t,.�_•;x �'.,�'-d .L�.•y.' S A" c .�, h� j_ � �'���s-� ' a Lit�. i'�'
<br /> � '� ,�a:1>� Xr��,'#e �- � �''•�����" ".� ,t rC.F^ .�,_,. � � p.. .�.�.;r'y�n A �� ,� zr�ex���l. �"�.'��'�r���3 �s..-.,
<br /> 18.Designated Facility Owner or Operator.Certification of receipt of materials covered by the manifest except as noted in Item 17a
<br /> Pnntedlfyped Name / Signature,,. Month Day Year
<br /> 169-BLC-0 6 10498(Rev.9109) TRANSP®RTE111#1
<br />
|