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G) 0 Q <br /> v CIDQ <br /> 17D ; (n <br /> � r <br /> v (D <br /> 00 <br /> HOH-HA2ARa6115 1.Generator ID Number 2.Page 1 df 3.Emergefvy Response Phare 4"Waste Tracking Number N <br /> C:)M <br /> �J N WASTE MANIFEST <br /> Ill 5,Gettaralot's Name and Ala Ing Address Gerferator's Slte Address of different than madirg address} N <br /> _ 5'r ; <br /> 1.— <br /> Generators Prune: r U.S-EPA ID Number v <br /> B-Transporter 1 CorcgtarryName + 1n <br /> Cn <br /> '1 3 <br /> 0J.Transporter 2 Company Name .S.EPA IP Number <br /> Q. <br /> QQ <br /> 17p O <br /> 17D B.Designated Facility Name and Site Address U-S.EPA ID Number Z) <br /> Cf) <br /> Faxili <br /> �• <br /> g.waste Shipping Name and pescrgtion to-Conmem 11-Total 12.Unit <br /> � No. Type Duamiry W1Nol- <br /> � a <br /> w <br /> O lu 2. <br /> � C! <br /> O a- <br /> 13,Spout Handling lnsmxlons and Additional Information <br /> A 14.GENERATQR'MFFEROR'S CERTIFICATIDN;I hereby declare mat Bre oDnfanis of this cansgnment are tulty and accurately described above by the proper ahippmg name,and ars classdiad,packaged. <br /> : . <br /> marked and IatieledlplaCarded,and are in all respects in properoorrditionlpf transport according to aypkcable international and rational govsmr>aatal regulation, 1 <br /> GeneratofslDNerols PnntedTyped Name Sly nature Month Day Year <br /> i <br /> 15.IntpmatlonaEShipments <br /> k ❑import to U.S. 0 Expert Iron U.S. Pori o!an1ry7u1' <br /> Trdn order kurs Ilof ex ns 0 Date tab U-S-: <br /> t w 15.TwWoder Ackrmwtedgment of Recut of Materials <br /> iTranspaner3 PrirteVyped Name Signature M" Day Year <br /> 0 <br /> a <br /> N <br /> asa TrarlSppner 2 PrintedlTyped Name Signature Mwrth Day Year <br /> F <br /> 17 Di%wafq <br /> 'n 17a.Discrapa q Irx&alion Space <br /> ❑DuenSly ❑Typo ❑Residue ❑Parua]Rejec4on ❑Fdl Re(8c0on <br /> Manilest Raleren[e Number; <br /> 11b.Alternate Facility(a Generator) U-S-EPA ID Number <br /> 1 <br /> Facilkys Phone: 0 � <br /> � (D <br /> I 7e.Sgnatum of Altemare Fapkty(or GBnaralor) MVMear 14 <br /> � Y 0 O <br /> _ � Q <br /> 0 3 <br /> m •• p <br /> 15.Desgnated Fadlmy Nhar or Operator.Cerokaiipn of reoeipr W matenels caroted by the manliest except as noted in item 17a <br /> (Sl <br /> Primed,7yped Name Signature Iso" Day Year <br /> � N <br /> CD <br /> N i69-BLC-O 5 11977(Rev.9/09) GENERATOR'SISMIPPER'S INITIAL COPY 00 <br /> O <br /> N <br />