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MflH•HR2AR40US 1• erler8tar10 Number 2.Page 1 of 3.Emergency R <br /> WASTE MANIFEST 4 �.. ovo5 a3'nry��g 11111^fe�(. 4•Waste Tracking Mrtmhar <br /> 5-Generator's Name and Mating Address ■1*I4-S+7 f� ���7G 9'ry/1/ L d C Generator's Srfess(A difl'erenf than mailing address) <br /> Generators Phone; Zo�r r --7 1/1 '7,#—'-7 <br /> 6-7ranSpeder 1Cornpany Name <br /> t� GC)A/ ETfI/I G �s U.S.EPA fD Number <br /> 7.Transporter 2 Company Marne =- ' `�n';1 <br /> U.S.EPA ID Number <br /> 8.Design�atred FarlrityName and Sita Address T� ❑ ✓C <br /> �'r����� U.S.EAA-1 0 Number <br /> Facdi 'S Phone: `707.`13 Z <br /> 9.Wasle Shipping Name and pesenplion 10.Conlalners <br /> 11.7oial 12.Und <br /> n 1/y/ �y T�C �ry� Na. Type 4uan6ry MAO. <br /> LU 2 f.• �; <br /> CS <br /> 3. <br /> 4. <br /> 13.Special Handling Instructions and Addifional information <br /> V" <br /> 1EL Emir✓ <br /> 14,GENERATOR'SlGFFEp flR'S CERTIFICATION:i Hereby declare that the rgnlerrts of Ihfs J i <br /> marked and fabeledlpiacaW.and are in al!respects in proper condifico for Transport apco mens are lulfy and acmnlely described above by the pmper shipping name,and are Gasified,packaged, <br /> Generaioegeofferars Pn11-1 yped Name ng stip)cable in[ematiOnal and national govermrlental regufations- <br /> t Signafura. <br /> . M°n� Day Year <br /> -J 15-intemaaonaJ Shipments <br /> F' ❑impar!to U-S. <br /> ? Trans niter Si aiura tar ex its oru 11 Export rrorn U.S. Pon at entryle>ak <br /> 16.Transporter Acknowledgment of ReUiPi Of Materials Gale ie9 U.S.; <br /> Transporter 1 Pdntedrfypyd Name <br /> ❑ Signature <br /> aco Mw1h Day Year <br /> Transposer 2 Pdnledlfyped Name <br /> Signature Month pay Year <br /> 17.Dwepancy <br /> 17a.piscreparlcy Indication Spare <br /> ❑Quantity ❑Type ❑Resiarm ❑Penial Aejettion ❑Fu9 Rejection <br /> 171b.Atiemate Facrl ly IOr GeneralOrl Manifest Reference Nmtteec <br /> V <br /> U 5-EPR ID Number <br /> tQ FaAky'sPhare; <br /> C3 <br /> 17c.Signature of Af[emate Facifi <br /> ry{a Generator] <br /> a <br /> z Month pay Year <br /> 18.pesignared Facility Owner❑r Operator-Certikabon of receipl of maleriafs covered by the manifest except as noted m Itam 17a <br /> PriatedrTypedl Name <br /> Signature klonm Gay Year <br /> 169-BLC-05 11977(Rev.9109) <br /> GENE RATCR'SISHIPPER'S INITIAL COPY <br />