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Q <br /> , (n <br /> W �3 t oQJ CD � <br /> 77 a ° � <br /> C: <br /> v HON-HAZARDOUS I-Gerteramr B N 2.Paas 1 a a Emergm Response Phone k.Wakk Tra%ng Humber Np f 1 <br /> `r WASTE MANIFEST AC U N <br /> N s.Generators Nerve and Mailing Address • . <br /> _ f`, 1" rJ F Generators Site Add ass{!diRe ent than mailing add ess} N) <br /> U) o <br /> v' GenereforsPhare: - <br /> �+ 8-Transporter 1 Ggnpany Name v <br /> U-S-EPA 10 Nunber (n <br /> v� 3 <br /> (`gyp 7,Tranvoder 2 Company Name <br /> U.S.EPA Ip Number QQ <br /> CD O <br /> S.Designated Facility New and Site Address r r Z) <br /> I I.• I U-3.EPA tp Number Cl) <br /> Faiili•s Phone ' ^}�• �.� •--F <br /> i '1 <br /> 0• 9-Waste Shipping Name and Description 10,Containers 11.Talar t2.Unit <br /> Ho. Type Quantity WINol- <br /> ¢ ¢ 1 <br /> O ,A <br /> w 2. <br /> l"r <br /> �• 3- <br /> O <br /> 4- <br /> 1 13-Special Handling insinx imis and Awtutal Inrom3addn <br /> 14,GENERATDR'WFFERDR'S CERTMCATIM:I hereby declare that me comps of pus oarsignment aro LrWy and aowralsy desc+ibed alowe by tW Prop,5�uppirrg urne,and are das&ried• <br /> marked and iabefedrptecarded,and are m all respects in Proper mndirlon fcv transport awmifng to BP*We cternational and national gowemmenw raguworrs. . <br /> Ganeratars+OHamrs Pftted Typed Name sgnatura March Day veaz <br /> tI' <br /> rf5^Intemalional Shipments <br /> 13 imp.to vs. ❑Export from U.S. Port of arVrylont: <br /> Tr r turn tar ra Date U.S.: <br /> F w 18.Transporter AclwwWgm m of Receipt d Meter" <br /> Trane mrlar 1 Prpetedlryped HamaSignature <br /> . _ +AOmn oay Year <br /> _. <br /> N 1 i J <br /> a Transpose,2 Prirned?ypad Name Signature fAanpr •Day Year <br /> 17.Diwrepwq <br /> 17a.Discrepancy Indication Space ❑oumbly ❑TV. ❑Residue ❑Parbat Flojw" <br /> ❑Full Reyattion <br /> Afardesl Reiermce Number: <br /> 1To-Atlemate Faddy for Genergloo <br /> 13.5-EPA ID Number <br /> roc Fact7lty'S Phone: O n <br /> 17c.Signawnt d Abscriam Faallty(or Generator) Month v5v aD O <br /> z 3 <br /> 2 <br /> O <br /> Ia.Detgnatad Fanny Owner or C"rawr Cemfiicaeoo W racNpt of materials cowered by pre mardest except as naiad In Ilam 17a 1 <br /> Prrnt,�dTypW Name Signature MoMb Day Year N <br /> cD <br /> v W <br /> O 159-BLC•05 11977(Rev.9W) GENERATOR'SISHIPPER'S INITIAL COPY <br /> N <br />