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NON-HA7ARDbi1S 1.Generator ID Number 2,Page 1 of 3.Emergency Response Phone 4.Waste Tracking Number <br /> WASTE MANIFEST c003 eft �-4f Zq <br /> _ tyQ <br /> 5.Generator's Name and Mailing Address j �+ ,k G eras s Site Address(If different than mailfng address) <br /> 17 sin. <br /> 1 <br /> Q ,Rs Ph l�v® S+vet —� eis—�i,Phone: <br /> 5.Transporter 1 Camp y Name <br /> U.S.EPA 1D Number <br /> &. z god/Le, 1CJ� '7 Uf 'Y <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> 1 8.Designated Facility Name and Site AddressCole's <br /> ' ® P. U.S.EPA ID Number <br /> (,.oQe's J-4G• <br /> acifi 's Phone: �( 0 7 )CEA4A0' <br /> 9.Waste Shipping Name and Description <br /> 10.Containers 11.Total 12.Unit <br /> No, Type Quantity W1.Nol. <br /> W <br /> Lu 2. <br /> 3. <br /> 4. <br /> 13 Special Handling Instructions and Additionai Information <br /> PW CAa <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 class'died,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 /> Generator'slOff Printed/Typed Name Signa nth Day Year <br /> F <br /> - GE <br /> -u 15 International shipments <br /> Import to U.S. ❑E port from U-S <br /> EJ of entry/exit <br /> z Transporter Signature for exports only): Date 1pnWrin U.S.: <br /> w 16 Transporter Acknowledgment of Receipt ofYaterids <br /> oTransporter 1 Printed/Typed Name Signature a Mon Day Year <br /> I to <br /> z Transporter 2 PrinledrTyped Name Month ay Year <br /> Icc <br /> 'r <br /> i <br /> 17 Discrepancy <br /> 17a.Discrepancy Indication Space <br /> ❑Quantity ❑Type ❑Residue ❑Partial Rejection ❑Full Rejection <br /> Manifest Reference Number: <br /> 1 r 17b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> I "r <br /> V <br /> rat Facility's Phone: <br /> F17c.Signature of ARemate Facility(or Generator) Month bay Year 1 <br /> a <br /> z <br /> c7 <br /> it w <br /> � o <br /> 18.Designated Facility Owner or Operator;Certification of receipt of materials covered by the mandest except as noted in Item 17a <br /> Pdntedi'fyped Name Signature Month Day Year <br /> 169-BLC-0 6 10498(Rev.9109) IGNA D FACILITY TO GENERATOR <br />