Laserfiche WebLink
Month Day Year <br />i3 I 1/ 1 1 <br />Month Day Year <br />1 01) <br />LI Full Rejection <br />Month Day Year <br />DESIGNATED FACILITY TO GENERATOR <br />NON-HAZARDOUS <br />WASTE MANIFEST <br />1. Generator ID Number 2. Page 1 of <br />)(2-'" <br />3. Emergency Response Phone 4. Waste Tracking Number <br />)1 -1-1. Co0 ED \ <br />Generators Name and Mailing Address %Imp-4 pfrLb---Ac-- <br />Generators Phone:( I \e..) 5- ICC) - 4:3f=k c) <br />Transporter 1 Company Name <br />A‘--t-c-Z_N <br />Generators Site Address (if different than mailing addressl eit c_ <br />co ss 55-‘131 <br />S72:› <br />Received <br />U.S. EPA ID Number <br />C--PN-1> O'S-5-Slob -s9 <br />Trporter 2 ompany Name <br />0 V LikiA LIAC <br />U.-PAD Number <br />APR 1 2 2021 A( )__c-Liceto( <br />Designated Facili acne and Site Address <br />CZ-50SA:t •=0NO .k-Z-.1.-0,......\ <br />vq-Tli ST' <br />c, '231'3 <br />Facility's Phone: ( SN,'"2:\) - sA-10, <br />U.S. EPA ID Number <br />GHD <br />Indianapolis crz,s'-iD9 e <br />10. Containers 11. Total <br />Quantity <br />12. Unit <br />WtNol. Waste Shipping Name and Description <br />1. <br />wo..3 - e...Vicfmcz_NAN-k_ tz. <br />S"?‘•-) <br />NO. Type <br />- STE 1I-1- <br />ALL op T71,, <br />Boo <br />0 AccEpr - - <br />Fie RESOURCE CUNsER,v.4 ',.••• • <br />•-• <br />ACT"./.3;'IN-D9764T40GETPU <br />nThWTrfiPR°.4.PPVLS..!_TchrASLPP <br />•••.,,L,:•‘70,ts, RAs <br />.4Tru <br />evirixotilm r ; <br />DE.PART?..e.a. OE <br />Toxic su3s-r.r4 ?qr.. 7-1-._uNTRI-110CL.D rr."-:TOGE'llER"L*IR <br />i-EDERAL AND <br />nee REPIIii(r U/A <br />_ _ <br />OLSPocay cEr . ritt,rmpm. y -). • il-ANDLEO AND <br />PoR s <br />:S.RAtris GRANTED To TuE... _"'"a'r ovERT0N. (NC • ERATEs U2441.13;:iVr <br />Special Handling Instructions and Additional Information <br />-2;3‘A. <br />-?t* <br />*F 1. 2...t • .eoz) 6 it/ ”'ee7 <br />GENERATOR'S/OFFEROR'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 />marked and labeled/placarded, and are in all respects in proper condition for transport according to applicable iaemational and national governmental regulations. <br />Generators/Offerors Printed/Typed Name <br />€X-C-. ‘..P17_r) I <br />SignattD) Month Day Year <br />International Shipments El Import to U.S. 0 Export from U.S. V Po en /exit <br />Transporter Signature (for exports only): Date leaving U.S.: <br />16. Transporter Acknowledgment of Receipt of M abnals <br />17a. Discrepancy Indication Space I-_I1 <br />I_ Quantity 0 Type 1111 Residue LI Partial Rejection TRANSPORTER Signature (/ <br />porter 1 Printed/Typed Name <br />don b-c-ki- <br />Tran .poren 2 Printed/Typed Name A <br />tt cT- t it c. <br />17. Discrepancy <br />Manifest Reference Number. <br />17b. Alternate Facility (or Generator) <br />Facility's Phone: <br />U.S. EPA ID Number <br />17c. Signature of Alternate Facility (or Generator) <br />18. esignated Facility Owner or Operator. Certification of receipt of materials covered by the manifest except as noted in Item 17a <br />Signature <br />1 <br /> Printed/Typert N <br />169-BLC-0 5 11977 (Rev. 9/09) <br />- -