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(D C2 <br /> N <br /> W p V7 <br /> 0 CD NOH-HAZARDOUS t.Generator 16 Number 2.page 1 m 3.Emergency Response Phme R Waste Tracltlrlg Humber W � <br /> WASTE MANIFEST N j <br /> IM n �' 5.Generator's Name and Mailing Address Generator's Ste Address{d Newt than maQV address) C:)" <br /> N Cn <br /> IM <br /> Cn O Generators Plane- <br /> 6.Trartsfgner 1 Company Name <br /> � U.S.EPA IG Number <br /> C <br /> 7.Trend orter2 Company Nam �< <br /> U.S.EPA ID Number (n <br /> � 3 <br /> CD B.Desipnaled Fadlq Name and Sde Address U-S.EPA 11)Number <br /> Q- <br /> O <br /> (D 0 <br /> CD <br /> F .. 'e Phone- <br /> 9.Wore Shipp-ng Name and Oescliptien iD'Co 11-Total 12-Una <br /> No. Type OLw* WI Nd. <br /> O c <br /> rr <br /> 2. <br /> ¢ m <br /> O wn <br /> CD 3 <br /> O a. <br /> 13.Spatial Handling lnslnrc9ons and Additional Information <br /> i <br /> 16.GENERATOR'SlOFFERORS CERTIRCATION:I hereby declare that ft contents of M mrrpynmanl are MIY end a=ral*desated above by the proper slupplrng name,and are dawfied packaged <br /> marked and iabeled'piacafeed,and are m all respects in proper condition for lrargW according to applicable imematioq am nakrLal <br /> govanxnenlel regulalgris. <br /> Ganem&sJWero(5 Pdn!W7yped Name signature MOM Day Year <br /> 15.fntemational Shipments <br /> '�l ❑import to U.S ❑Fxyorl Fran US. Port of BMryle�dt <br /> Tfw&Wof Signarure Ifore its orayy Dale lea i- U.S.: <br /> - ¢ 1$.Trdnsporter Acknowledgment o1 Receipt of Malaria$ <br /> Transporter 7 Pnnledrfyped Name Signature MMnlh Day Year <br /> a <br /> N <br /> 2 Transporter 2 ArinleciTypad Name Signalure <br /> Month Day Year <br /> r <br /> 17.Diserepaoey <br /> 17a.Discrepancy 1ndieabon Spacr ❑Ouanbty ❑T ❑ <br /> YPa Residue ❑Partial ReJecllon ❑FWI Rejecxion <br /> {' Mendes)Reference Number; <br /> r 17t.Aryemata Faat<1y for Generator) <br /> t U.S.EPA Ip Hmber <br /> J <br /> U <br /> Facif4,s Mnrw- <br /> N17c.Si a9lure of AlI mare Facility Idr Genera* MW..h Day Year <br /> a <br /> o CD <br /> 0 n <br /> O <br /> Sv Q <br /> 18.Desrgnaled F&Idjty Owner of Operator:Ge6kabon of lecelpl Of malenals corned by the nynilasi excep as opted N Item i 7 3 <br /> PnnledrTyped Name Slgnefure M" bey Year _ C_ <br /> O <br /> 169-OLC-0 5 11977(Rev.9M) GENERATOR'S/SHIPPER'S 1N1TIIAL COPY 01 <br /> � 1 <br /> Sv � <br /> (Q N <br /> CD <br /> Cb <br /> O <br /> N <br />