Laserfiche WebLink
J � Q <br /> Q- <br /> W NON•HA2ARDp US t.Generalor M Number 2.Page 1 of 3.Emergency Response Phone 4.Waafe Tracking Humber N <br /> 7 Q. WASTE MANIFEST I r I ,1 j N <br /> n 5.Generators Name and Mating Address Generators SRe Address Id different Than mailing address] 0 I fl <br /> N <br /> �0 N {�7L STti , , . , L1.L cn <br /> M pa <br /> N <br /> _ -i <br /> U) p Generators Phone: <br /> 6 Transporter 4 Company Name U.S.EPA ID Number G <br /> 7.7ranspodar2 Company Name U.S.EPA ID Number ' <br /> CD �. <br /> ¢ 8.Deslgnalsd Facility Name end Re Address U.S.EPA ID Number <br /> CD 0 <br /> 'l_ fir. T-'C ,I.f-1.r Z.1 [. r'• C <br /> 7Waaciri3ne; i : --1 5 .�1,? -11ste Shipping Name and Descrgption 10.Corrlainers 71,Tela) 12.Unit <br /> • Nd. Ty Pe Querroh WtNd. <br /> O ¢ <br /> i 2. <br /> CD <br /> r� <br /> O <br /> 4. <br /> t3.Spedal Handling IrtsWdons and Ad*rionnaf Information <br /> 14.GENERATOR'SIOFFEROR'S CERTIFICATION:l hereby dedere that the Contents of dtis consignment are fulhy and accurmtery described above by the Proper Shipping name and aye da=fied,packaged, <br /> marked and labeledlplacarded,and are In all respects in pnuper cord bon for transport according to app6cabte In[ernaaonal and national govemmentw re.L Bom_ <br /> Gene ators paeyes PrinteC7yped Narne Signature <br /> Mon81 Day Year <br /> .j 15.IMemational SNpments _.. _ . <br /> i ❑import to U.S. ❑E�Wrt from U.S. Pan or erl4ylea <br /> Trartsporler Signalure Lkw exports on : Da1e Ieari U.S.: <br /> 16.Transporter A*nowledg<Irenr dl Recelpl of Mereriats <br /> Transporler t Printed?yped Name <br /> n Signature Montt Day Year <br /> y <br /> a TfansNrler 2 PrinteNFyped Name Signature Month pay Year <br /> m <br /> 17.Discrepancy <br /> 17a.Discrepancy Irdoation Space ❑Ouantiry ❑7 <br /> �p ❑Rd, ❑PaNal ReIedm ❑Furl Refachon <br /> Manliest RBIBierlCg Number, <br /> 17b.Alrernale Faci ily td Generatdrl U.S.EPA ID Number <br /> U <br /> res Faafy's Phone: <br /> 17C-Sigrtalure of Ademele Faa>ity for Gerrelal (Der) Mvnih Day Year (Q 00 <br /> L7 <br /> C_ <br /> i8-f7es gnaled Facility Oww or Operator.Gerlifi cn of receipt of maWmK covered by the man9est e:eepl as Woe in nem 17a � <br /> (S <br /> Prrnted7yped Name $Ignalure Mmes Day Year � <br /> (Q N <br /> (D <br /> 00 769-8LC-0 5 11977(Rei.9109) <br /> GENERATOR'SISHIPPER'S INITIAL COPY 00 <br /> O <br /> N <br />