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R—� <br /> Q- <br /> - <br /> (D m (n <br /> � <br /> C <br /> NCD ON-HAZARDOUS 1.Generator t9 Number 2.Page 1 W 3.Emergency Response Phone A.Weare Traokfag Number ' <br /> 00 <br /> 77 <br /> cn WASTE MANIFEST <br /> M <br /> �n 5.Generator s Narte and n9 Address Generators Site Address Id dilfererg Mn mailing address] <br /> C) <br /> 01 <br /> fll <br /> = a• t yds WL <br /> cf) O Generamrs Pndrre: `I S b -t -' <br /> 6.Trarlsponer 1 Company Name U.S.EPA ID NurrW <br /> 7 TmnspoAer 2 Company Name U.S.EPA ID Number 3 <br /> e--r <br /> rD �. <br /> Q.. 8.Designaled Fscivy Name and Sile AddrBss U.S.EPA 11)Number <br /> ✓, r i , r. r. , i-r L O <br /> r.. r t-: l y 17 4v "7 <br /> q y cn <br /> • <br /> Fadi Ws Phone: <br /> N <br /> 1011. 12. <br /> 8.Waste Shlpong Name and Descriprlon -Centaiflers No. Type Owunti y, YAW. <br /> �.. '1 <br /> 1. .. r. <br /> O a - <br /> ur 2 <br /> td <br /> A� 3. <br /> O <br /> d, <br /> 13.Special Handing Instr irks and Additional Information <br /> r .- •- - �lr•!Lis - I -- - r' r i I <br /> .. t <br /> 1 <br /> N.GERERATOR'SMFFEROR'S CERTIFICATION:I hereby dedare mat the contents d this consignment are Mly and aaanately described above try ore proper yapping name,and are classified,padoged, <br /> marked and laheleyplacarded,end are In ay respells in proper cardBidn}Or Transport aocarding to epplirabla inlerrls6orml and nagOnal goyemmenlat regulations- <br /> .. Generalors+xerorsPrin[edaypedName Slgnalure - lionN Day Year <br /> 15-Irdemalionar Sh�pments ❑Import to U.S- ❑F*ert lrom U.S. Port of emrylaxll: <br /> Transpomar Swarturs,for ns Date leaven U.S: <br /> cc 16.Transporter A.cknorrtedgmarll of Reoeipt of Materials <br /> oTranspor9er•1 PrinledRyped Name Signature Mudh pay Year <br /> a Trucporrer 2 PdMedffyped Name gym <br /> Monty Day Year <br /> F <br /> 17. -Ey <br /> 118.ascrepancy tvd-ice iod SpKg <br /> ❑Guanuly ❑7ypB ❑Residue ❑Paro91 Rbjautidn ❑FuN Rejection <br /> 11—ileal Reference Nunber- <br /> 17b-A1:emete Pettily(of Generator) U.S.EPA1D Number <br /> Facials Phow <br /> w T7c.57rature of AIlemate Faclhry for Generator) (D <br /> a r*� � Y- O O <br /> z v 0 <br /> 18.Des grated Fac f ty Owner w Operator Cendicalron of receipi of malereale cmred try ft manifest except as noted n llem,17a O <br /> Printedrfyped Name <br /> Slgnalure Mwoh D8 Ybar � <br /> Y <br /> (S] N <br /> (D � <br /> ifi&9LC•O S 11977{Rev.5VD9j ENERATOR'SISHIPPER'S INITIAL COPY °D <br /> 0 AL <br /> N <br />