Laserfiche WebLink
169 -ULC -O 6 10490 (Rev. 9/06) %+v TRANSPfiRTER-421 <br />NON -HAZARDOUS 1. Generator ID Number <br />2. Page i o1 8, Emergency Response Phone 4, Waste Tracking Number <br />-� <br />WASTE MANIFEST E;; ,spy �. !k g'1, fi "0 f <br />Yy ,� k : t R '2 `, <br />5 Generator's Name and Mailing Address <br />/ „ rr:6R$h'9'iaxi &#Cao". Generator's Site Address (it different than mailing address) <br />CA W206 <br />Generator's Phone: 2W11 <br />8. Traneponar 1 Company Name <br />U.S. EPA ID Number <br />C A 0 ? <br />7 4a <br />7 <br />7. Transporter 2 Company Name <br />U.S. EPA ID Number <br />mw``aPd ei➢ koff#iftbCE4 'a <br />8. Designated Facility Name and She Address <br />1, xf'4 <br />U.S. EPA - Number <br />VI w= a' 8 <br />ton som pmfk nam <br />- MIDSWA M 30474 <br />Fact II's Phone: ;a-rva;4 <br />9. Waste Shipping Name and Description <br />10. Containers 11. Total 12. Unit <br />- <br />No. Type Ouetily IN~ <br />1, <br />all <br />2. <br />4 <br />10. Special Handling Instructions and Addllional hFinan al cn <br />IF <br />14. GENERATOR'S CERTIFICATION: I certify the materials desc bed above <br />on Ibis manifest are not subject to federal regulations for storming proper d'Dpacal of Hazardous Waste. <br />G <br />Generator's/Offeror's PnmedR etl Name <br />yP <br />Signature { <br />Month Day <br />Year <br />TJ <br />r <br />15. intematlonal Shipments <br />❑ Import to U.S. <br />❑ Export from US. Pod <br />— <br />ofentry/exit: <br />Trans der Sl nature for ex ohs onl <br />_ Oale leavin US.: <br />so <br />18. transporter Acknowledgment of Receipt of Materials <br />s <br />Transporter 1 Printed?yped Name <br />Signature,7 +. <br />Month Day <br />YearOIL, <br />r <br />so <br />r; <br />j <br />¢2! <br />Transporter 2Pnnted/Typed Name <br />Signature e <br />Month Day <br />Year <br />lir:'Li <br />fi <br />17. Discrepancy <br />- <br />¢/ <br />pA� <br />�I <br />17m Discrepancy Indication Space <br />❑ Ouantity <br />❑ Type ❑ Residue ❑ <br />❑ <br />Partial Rejection <br />Full Rejectlon <br />Manifest Reference Number: <br />17b. Alternate Facility (or Generator) <br />U.S. EPA ID Number <br />ti <br />U <br />It; <br />Facility's Phone: <br />2n <br />an <br />17c. Signaiureof Alternate Facility (or Generator) <br />}+ <br />Month Day <br />Year <br />z <br />Q <br />as <br />® <br />=ej <br />18. Designated Facility Owner or Operator Cerliflcalion of receipl o(matedals covered by the manifest except as noted in Item 17a <br />h8 <br />Printed/Typed Name5 ; <br />i <br />Signature (`f .ifFJ <br />M nth Day <br />Yepr <br />f <br />A('='Ft if /� '71' <br />t <br />/Cf`r.:�.+/r� <br />