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NON-HAZARDOUS I.Generator ID Number 2.Page 1 oftsqoo—nN <br /> Emergency Response Phone 4.Weato Trackin Number <br /> WASTE MANIFEST s <br /> 5.Ges tn� ame and ailing A cess Gener's SitsAod ss(if di(#erent n maig address) <br /> enaratas Ph 0' ■ zu 42-I <br /> 6.Transpo 1 oN U.S.EPA ID Number <br /> M 7fz4Z <br /> 7.Transporter 2 Company Name U.S.EPA ID Numhe <br /> SUf?�SCd Fapility Nine and Ad nese U.5.EPA ID Number <br /> Facilli s Rhone: P�"i� [f� <br /> 9.Waste Shipping Name and Description 10.Containers 11.Total 12.Unit <br /> No. Type Quantity M.Nol. <br /> 1. <br /> cc <br /> 2. <br /> LU <br /> 3. <br /> 4. <br /> 13,Special Handling Instructions and Ad I <br /> pinnal Information <br /> S � I q�-�/60'p f �)o - -A ,L -, �0 <br /> ol p1w, <br /> �JI� 0.- 1 G!v <br /> ftf�� X02 0 <br /> 14.GENERATOR'SIOFFEROR'S CERTIFICATION:I hereby declare that the contents of this consignment are fully and accurately described above by the proper shipping name,and are classified,packaged, <br /> MPV and labolecUplalarded,and ars in all repects in proper co icon for transport according to applicable mational and natiogal governmental re IaWns. <br /> Gen r'srF' t yped N Sgna213 <br /> Year_ <br /> 1W 1 <br /> —1 15.Ince ational Shipments Import to U.S. ❑Export from U.S. Port of entry/exit: <br /> Trans Wer Signature for exports only): Date leaving U.S.: <br /> iE 16.Transporter Acknowtodgment of Receipt of Materials <br /> Transporter t PnmedrTyped Namea Signature Mon Year <br /> a 1 n j1rn y L <br /> a <br /> M <br /> a Transporter 2 PrintedrTyped Name Signature Month Day Year <br /> 17.Discrepancy <br /> 17a.Discrepancy Indication Space ❑T EJ Residue <br /> Ll quantity Type ❑Perlia]Rejection ❑Full Rejection <br /> Manifest Reference Number: <br /> 17b.Allamate Facility(or Generator) U.S.EPA ID Number <br /> U <br /> Facility's Phone: <br /> 17c.Signature of Alternate Facility(or Generator) Month Day Year <br /> x <br /> 2 <br /> c <br /> 18.Designated Facility Owner or Operator:Cerci o of receipt of materials covered by the manifest except as noted Item 17a <br /> Printed/Typed Name Signature th a r <br /> 169-BLC-0 5 11977(Rev.9109) DESIGNATED FACILITY O GENERATOR <br /> C <br />