Laserfiche WebLink
r <br /> t <br /> Aw <br /> �4. racldn Number <br /> 3.Eme en Res nse Phone 91.Generaror ID Numbsr2.Page 1 of _ rg cy PoN-HAZAR00i NO . <br /> �, ��-- .. <br /> '3 <br /> `i # <br /> WASTE(41ANIFEST „'�� 501 .. <br /> raGenerators Site Address(if different than mailing address) <br /> 5.Genetor`s Name and Mailing Address <br /> :A 1004 (113) 7"9r3�-} Wit-, r.'sw. �.'� 152 <br /> Generaror s 79b"' ' U.S.EPA ID Number <br /> 6.Transpoder 1 Company Name <br /> ''�_IE'w '"�-ltl:� t.�3ti. :.�;` -IRO ��.� <br /> U.S.EPA ID Number <br /> 7.Transporter 2 Company Name <br /> 8.Designated Fackity Name and-Sfte Address U.S.EPA ID Number <br /> f :';irf 't"L117f'�xv <br /> 1019 77.. <br /> Facil' s PA-- ' <br /> 10.Containers 11.Total 12,Unit <br /> 9a. 9b,U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, No, Type Quantity W1Nol. <br /> HM and Packing Group(if any)) <br /> 1. .. )l`1•�:si.'�w; r311 i �,3 i� ?'a i't 6 z L.. s s y 7 ar • cRR <br /> aUl <br /> cc <br /> W2. .., � <br /> 13. Special Handling Instructions and Additional Information <br /> i ?i7.�� �3t�����:S�t.",�'.3i3'.~< 'rl'i�t3•�; a��V'�-?rta %� �i??�i��t3t3 - <br /> 14.GENERATOR'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 /> Generator'sIONeroPs PtImedffyped Name Signature Month Duty._.,.�Yeear <br /> X9 i i t t r e <br /> J 15.International Shipments ❑Import to U.S. ❑Export from U.S_. Port of emrylexrt: <br /> Z <br /> — Trans rtes Signature for exports on Data teavin U.S.: <br /> cc 16.Transporter Acknowledgment of Receipt of Materials ."` <br /> Signature,, Month Days.Ye <br /> Transportgr J Printed(Typed Name :; 7 '';`" j °''s _ f d <br /> ,�1 a j f' fro ✓�. �!t,/. i`rf e-;..` :;:�'�R`.J, w2."'Q'rfw'' .,,,. �`^"3 � I <br /> N Signature Month Day Year <br /> = Transporter.2 Printe&Typed N e <br /> a <br /> F <br /> 17.Discrepancy <br /> 17a.Discrepancy Indication Space ❑Quantity ❑Type ❑Residue ❑Partial Rejection ❑Full Rejection <br /> i <br /> Manifest Reference Number. <br /> I 17b.Aftemale Facility(or Generator) U.S.EPA ID Number <br /> J_ <br /> t U <br /> rat Facility's Phone: <br /> 0 Signature of A@emate Facility(or Generator)Uj <br /> Month Day Year <br /> ,a� �4, ., s �e`a 'i .' �-u a _ut.s� - o ��;:A_ #_� _•x.-�... "�,�.-_: >' r� � 3n � '.w_ �:`.'"P�� - <br /> e� <br /> 18.pesignaied Facility Owner or Operator.Certification of receipt of Hazardous materials covered by the manifest except as noted in Item 178 <br /> PrintedfTyped Name Signature Month Day Year <br /> i� <br /> 169-BLC-0 6 10498 GEN ERATOR'SISHIPPER'S INITIAL COPY <br />