Laserfiche WebLink
NON-HAZARDOU <br /> S <br /> 1.Generator ID Number 2.Page I of 3.Emergency Response Phone Waste Tracking Number <br /> I <br /> WASTE MANIFEST I F:-, <br /> 5.Generators Name and Mal Address Generator's Site Address(if different than mailing address) <br /> ' hAl 1*001w Covftp"I,1'r,C;0 t-V i, f'ttry rw4p 14w,�o <br /> 0",4'0,14 A41f ACV. 'A",T,74, <br /> Generator's Phone:,.,i}, 4,,-1-ki, <br /> 6 Transporter 1 Company Name U.S.EPA ID Number <br /> !*xj f*;4 Pav 4,omwwal At 1-w% vw:;11#t ..-"I <br /> 7.Transporter 2 Company Name U.S,EPA ID Number <br /> 8,Designated Facility Name and Site Address U.S.EPA ID Number <br /> VVIAV� 142"Vvaae4s1 111'A"WaA I <br /> I QV,ii5 %Rxrukint <br /> Lv 0 A <br /> FacifiWsPhaie: <br /> 9,Woe Shliping Name and Description 10.Containers 11.Total 12.Unit <br /> No. Type Ouarrifty Wt.Noi. <br /> Roww'bal�'d Oil$ Nt <br /> z <br /> Lu 2. <br /> ry <br /> 3, <br /> ........ ... <br /> 4, <br /> 13.Special Handling instructions and Additional fnlcrmation <br /> 14.GENERATOR'SIOFFEROR'S CERTIFICATION.,I hereby dedare that the contents of this consignment are fully and=uralety Oescnbed above by the proper shipping name,and are classified,packaged.: <br /> marked and labaledroacarded,and are in aft respects 41 pruper condifion for transport acourding IU applicable international and national governmental regulations. <br /> Generalor's!Ctleto(s PnrtedfTyped Name Signature Month Day Year <br /> -j 15.International Shipments <br /> 11 <br /> impart to U.S. ❑Evhrfro-rrn U.S. Port w."uyle-it, <br /> Z Transporter Signature Ifor exports only): Date Leaving U.S.: <br /> 16.Transporter Acknowledgment of Receipt of Materials <br /> Transporter 1 PrintediTyped Name Signature Month Day, Year <br /> 0 kw <br /> a. <br /> zTransporter 2 PrintedlTyped Name Signature Month Day Year <br /> 17 Discrepancy <br /> 17a,Discrepancy Indication Space ua 11 <br /> ' A Fill Rejection <br /> ElPartlal Rejection <br /> ManifW Rolereme Number <br /> 17b,Alternate Facility(or Generator) Ju U S.EPA ID Number <br /> JUN 9 <br /> u4 Facility's Phone: <br /> NI <br /> 17c.Signature of Alternate Facility(or Genera Month Day Year <br /> NVIRONIVIEiAz� <br /> I r7 A r7 n <br /> z <br /> trr <br /> to <br /> le.Designaled Facility Owner or Operator:Cenifitcationot receipt of materials covered by the marrift except as noted in Item fire <br /> PrintedfTyped Name Signature Mordh Day Year <br /> 69-BLC-0 6 10498(Rev.9109) GENERATORSISHIPPERS INITIAL COPY <br />