Laserfiche WebLink
NOH-HAZAR4OU5 t•Generator l)Number 2.Page 1 of 3-Emergency Response Phone 4.Waste Tracking Humber <br /> Y <br /> .. <br /> WASTE MANIFEST <br /> I <br /> 5.Generat es Mame and Maung Address Generators Re Address(ii different than mailing address) <br /> Generator's Phone: I"- �1} 14 , <br /> 6.Transporter 1 Company Name U.S.EPA ID Number <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> 6,Designated Facility Name and Site(Address U.S.EPA ID Number <br /> 'yl` ,L 1 +t, L l L <br /> Facie s Phone: ILL -2 46 <br /> 1fl-Containers 11.Total 12.Unil <br /> 9.Waste Shipping Name and Descr ption <br /> No. Type Quantity 1ArtNo1. <br /> W <br /> 8 2. <br /> W <br /> 3. <br /> 4. <br /> 13-S"i Handling lnstn,ctions and Addhonal Information <br /> 14,GENERATOR'SIOFFEROR'S CERTIFICATION:I hereby declare that the contents of this consignment are fully and aoouralely described above by the proper snipping name,and are ckssified.packaged, <br /> marked and labeleNplacerded,and are in all respects in proper condition for transport according to appllcable Intemational and nationat govemmantal regulstions- <br /> GeneratoCslDfferorsPrateciTyped Name Signalure Month Day Year <br /> 15.IntemaWnal Shipments <br /> 111 rnpon to U.S. Export tram U.S. Part of entryfexic <br /> ? Tran der Signature for ex ns Only): Date leavi U.S--: <br /> cc 16.Transporter Acknowledgment of Receipt of Materials <br /> w <br /> r— Transporter 1.Printedlryped Name Signature Month Day Year <br /> cc4 <br /> a <br /> fA <br /> a Transporter 2 Prmted+Typed Name Signature Month Day Year <br /> ccF <br /> 17.Diserepancy <br /> 17a,Discrepancy Indication Space ❑ ElPam RejecWn ElFoilRejeceen Quantity Type Residue <br /> Manllesl Ralarence Number <br /> 17b.klemale Facility for Generator) U-S.EPA ID Number <br /> J <br /> U <br /> LL Facility s Phone: <br /> 17c.Signature of Alremale Facility(or Generator) <br /> month Day Year <br /> 4 <br /> C7 <br /> �n <br /> w <br /> 18.Designaled Facility Owner or Operalor-Catficabon al receipt of materials covered by tho manifest except as noted in Item t7a <br /> PiinteOTyped Name Signalure Monti, Day Year <br /> 169-BLC-0 5 11977(Rev.9109) GENERATOR'S/SHIPPER'S INITIAL COPY <br />