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Please print or type.(Form designed for use on elite(12-pitch)typewriter.) q.Waste Tracking Number <br /> • NON-HAZARDOUS 1.Generator ID Numberfll 2.Page 1 of 3t Emergency Response Phone <br /> WASTE MANIFEST 1 <br /> 5.Generator's Name and Mailing Address Generator's Site Address(if different than mailing address) <br /> • t.k wit l r,;.orporatwn `:,AM i- <br /> nis N F61Kttar%rf44 <br /> �cmkicn l'rA. f►5,2'0': <br /> fl P'1 Generator's Phone: '39 441 H:4fKt U.S.EPA ID Number <br /> 6.Transporter 1 Company Name <br /> MitC:Enrrltrxin�ntal'SetvtCtas i�K. <br /> U.S.EPA ID Number <br /> 7.Transporter 2 Company Name <br /> • 8.Designated Facility Name and Site Addres U.S.EPA ID Number <br /> fain CtxaYM f:r�lAnt1NM <br /> ,tAlklri t •snc1Y 10,1 tf-tea <br /> tNq,„ri,r,-��t '•7, <br /> Facility's Phone: <br /> ga <br /> 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10,Containers 11.Total 12.Unit <br /> . HM and Packing Group(if any)) No. Type Quantity Wt.Nol. <br /> K <br /> � tJda NeZard4uro Vitaytr. `,agta,(fie 4+YAxte) <br /> I <br /> z 2 <br /> w <br /> c9 <br /> 3. <br /> 0 4, <br /> N <br /> N <br /> O <br /> E <br /> � 13.Special Handling Instructions and Additional Information <br /> E f'rOmilC" <br /> 72 <br /> Ft <br /> NERATOR'S CERTIFICATION: I certify the materials described above on this manifest are not subject to federal regulations for reporting proper disposal of Hazardous Waste. <br /> tor's/Offerors Printed/Typed Name <br /> Signature Month Day Year <br />' ational Shipments Import to U.S. ❑Export from U.S. Port of entrylexit: <br /> rter signature(for exports only): Date leaving U.S.: <br /> porterAcknowledgment of Receipt of Materals <br /> Signature Month Day Year <br /> er 1 Printed/Typed Nameer 2 Printed/Typed NameSignatureMonth Day Year <br /> 17.Discrepancy <br /> 1 17a.Discrepancy Indication Space Quantity ❑Type ❑Residue ❑Partial Rejection ❑Full Rejection <br /> Manifest Reference Number: <br /> U.S.EPA ID Number <br /> 17b.Alternate Facility(or Generator) <br /> J <br /> CU <br /> I Facility's Phone: Month Day Year <br /> w 17c.Signature ofAltemate Facility(or Generator) <br /> Q <br /> Z <br /> Q <br /> cn <br /> w <br /> 18,Designated Facility Owner or Operator:Certification of receipt of materials covered by the manifest except as noted in Item 17a Month Day Yeal <br /> PdntedrFyped Name Signature <br /> 6 NHM•C-C-11 &GENERATOR'S INITIAL COF <br />