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UNIVERSAL 1.Generator ID Number 2.Page I of 3.Emergency Response Phone 4.ftste Trackinumber <br /> g 1`4 <br /> WASTE MANIFEST 4 0"R693"ftj <br /> 5,Generators Name and Mailing Address Generator's Site Address(if different than m­ ng&l; address) <br /> V.4 riff."t <br /> :MPA24 f"lock <br /> Number b <br /> or <br /> Generator's Phone: 2r"0 <br /> 6.Transporter 1 Company Name <br /> '�VAW U.S.EPA 10 Number <br /> 1471AXX9X ►S> all rkxa <br /> 7.Transporter 2 Company Name <br /> U.S.EPA ID Number <br /> 8.D0te ; Namand <br /> Site Address U.S.EPA ID Number <br /> FaciliYs Phone: <br /> MAO$ <br /> 9.Vlaste Shipping Name and Description 10.Containers ON 111 jFM 139 <br /> L <br /> 11,Total 12.Unit <br /> No, Type Quantity wt./Vol. <br /> 0 ppit" <br /> z 2 <br /> Lu <br /> 3. <br /> 4, <br /> 13.Special Handling Instructions and Additional Information <br /> E at Mww', AM, Ali. tjXq'4; <br /> 'W'M". Wtia-e Vft4NBZ VIA", w' 'AWly <br /> Rao-itrout; <br /> VAP <br /> 14,GENERATOR'SIOFFERORIS CERTIFICATION;ION:I hereby declare that the contents of this consignment are fully and accurately described above by the proper shipping name,and are classified,packageO <br /> marked and fabeleWp%carded,and are in all respects in proper condition for transport according to app,idaNle international and national governmenlal regulations, <br /> Teneratoest'Offeror's'Printe Name <br /> S!gpliture Month Day Year <br /> lvlr� <br /> 16.International Sh'pments <br /> Transporter Signature JtLexarts only): Import I to U.S. El Export from U.S. Port of entry <br /> Date leaving U.S.: <br /> pq 16.Transporter AcknoAledgment of Receipt of Materiel$ <br /> Transppder-1 PdntWyped Name <br /> Signature <br /> Month Day Year <br /> 9 z Transporter 2 Printed/Typed Name Signature 'v <br /> Month Day Year <br /> 17.Dlscrepanq <br /> iia.Discrepancy indication Space Quantity Type El Residue ❑Part.]Rejection El Full Rejection <br /> 17b.Ailemale Facility(of Generator) Manifest Reference Number. <br /> U.S.EPA ID Number <br /> ua Facility's Phone: <br /> 0 <br /> 17c.Signature of Aftemate Facility(or Generator) <br /> Month Day Year <br /> Lu <br /> Lu <br /> 18.Designated Facility o aerorOpewoc Ceilkation of receipt of materials covered by the manifest except as noted in Item 17a <br /> Pr;ntedfTyped Name Signature Month Day <br /> Year <br /> QL-Jlr.)D170Q WITIA1 r1noV <br />