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<br />WASTE MANIFEST
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<br />2. Page 1 of 3 Emergency Response Phone 4. Waste Tracking Number ',..,i1;,,,,-;!..5e:,,,•:_2;ti 22,.2e14 ..r1.4)...:,, is Generator's Hanle ard M3ifri A.. ess Gerierator's See Address (it different than mailing address) ,r.1 . 7 ''. ' ' • i hi..10..4)6 (.7'.'4N;;.T.I1 ,.,: • . _ • ..,2.
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<br />Genmelor's phone:i.!.;1:0.460'i I. ii i..,'•;*,i I Transporter 1 Company Name; U.S. EPA ID Number P4PAI4V ight-letktrigliA0 Stireroit'el., j C 0 .ii . .if
<br />Transporters Company Name U.S. EPA It) Number -.
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<br />Designated Facility Name and Site Address U.S. EPA)!) Number Matt P4',, ik
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<br />, Phone: -1- .1',.4..' 3....01,4N I N !I 1'1
<br />Waste Shipping Name and Description Conlathers Total 12, Unit a. ,...
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<br />0 13, Special Handling
<br />i Instructions and Adcfitional intionnetion ) fnitti.,q i 1, i ..-.. • ;N , ' ILI.
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<br />GENERATOR'S/OFFER0R'S CERTIFICATION: I hereby declare that the contents di this consignment are fully and accurately described above by the proper stripling hamo, and are Classified, packaged,
<br />marked and labotedVacarde.d, and are in at respects in proper cor,chtion for transport according to applicable international and national governmental regulations.
<br />Generator's/Meets Printed,Typed Name Signature Month Day Year
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<br />III International Shipments 141 Import to U.S. 0 Export Irom U.S. Port of entry/exit Transporter Signature ((or exports only); Data leaving U.S.: ft4 -::.)
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<br />la Transporter AcknovdedgreeM of Receipt of Materials ,
<br />Transiorter 1 Printed/Typed Name Signature Month Pay Year / . ., i„
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<br />k Trarisdorter 2 PrintedtryPed Name Signalliki Month Day Yorir'
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<br />' ,-,1;;;":?;• 41% 4,--fiR.--71zt; 17. Disempancy
<br />Discrepancy Indicadc-n Space
<br />Quantity 0 Type . 0 Residue 0 Partial Rejection 0 Full Rejection
<br />Mealiest Reference Number:
<br />Alternate Faciity for Generator) U.S. EPA 10 Number
<br />Facility's Phone: I Signature of Alternate Facility for Generator) Month Day Year
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<br />18. Des;gnated Facility Owner or Operator: Certification at receipt of materials covered by the mandest except es noted in hem 17e
<br />PrIntorlaypod Name . Signature Month Day Year i
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<br />169-BLC-0 6 10498 (Rev. 9/09) TRANSPORTER 01
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