Laserfiche WebLink
x ' <br /> NON-FIAZARD)IJ 1.Generator ID Number 2.Page 1 of 3.Emergency Response Phone 4 Waste Tracking Number <br /> WASTE MANIFEST .7 i').9 �i � )'?'1-�3:3`3_�=��)7 <br /> Geneyrator's Silo Address(if different than mailing address) <br /> 5.Generator's Name and Mailing Address Uty' F L. Aa <br /> 3271 5;--rai La- <br /> Generators-- one s a <br /> ti _ r�.# <br /> _ U.S.EPA ID Number <br /> 6.Transporter 1 Company Name; <br /> U.S.EPA ID Number <br /> 7.Transporter 2 Company Name' <br /> a.Designated Facility Name and Site Address U.S.EPA ID Number. <br /> 2101 FE. lrwrlaj' a Ian's <br /> �,!i,-. 1d, '!a 1' 33,)7 (5t�1 1 537-13,552 <br /> Facil 'ssMone: <br /> t0.Containers 11total 12 Unit <br /> 9a, 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, , <br /> No Type <br /> Quantity WWoI. <br /> HM and Packing Group(If any)) . m< <br /> C '.' i—°' � :� �•. <br /> a l . <br /> w 2 { <br /> lu <br /> 3. <br /> 13. Special Handling Instructions and Additional Information <br /> as <br /> 14.GENERATOR'S CERTIFICATION:I cartify the materials described above on this manifest are not subject to federal regulations for reporting proper disposal of Hazardous Waste. Month Day.. Year <br /> GeneratorslOfferor's Printed}}rTyped Name Signature. _ <br /> .S•A•v�7: 1 - - -�r..✓-.- -.yam+ �-� L� 7 <br /> � 15.International Shipments^. ❑`import to U.S. ❑Export from U.S. Port of entry/exit: <br /> ? Transporter Signature for exports an <br /> Date leaving U.S.: <br /> CC UJ 16.Transporter Acknowiedgment of Receipt of Materials -Signature; ,` Month. Day„ year <br /> ' <br /> Transporter 1Orinfed/Tyrd Natpe <br /> p _ a I1,� 7. �+ <br /> CL Month Day Year <br /> ZTransporter Printed/Typed Natrie Signature <br /> H <br /> 17.Discrepancy <br /> 17a.Discrepancy Indication Space El Quantity ❑Type ❑Residue ❑Partial Rejection 0 Full Rejection <br /> Manifest Reference Number. <br /> • U.S.EPA 1D Number <br /> 17b.Alternate Facility(or Generator) <br /> V <br /> Facil'riy's Phone: Month Day Year <br /> LO 17c.Signature of Altemate Facility(or Generator) <br /> ra - <br /> w <br /> 18.Designated Facility Owner or operator.Certiflcation of receipt of hazardous materials covered by the manifest except as noted in Item 17a <br /> Printedrryped Name .Signature Month Day Year <br /> 169-BLC-0 6 10498 °' GENERATOR'S/SHIPPER'S INITIAL COPY . <br />