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NUN-HAZARDOUS 1.Generator ID Number 2.Page 1 of 3.Emergency Response Phone 4,Waste Tracking Number <br /> WASTE MANIFEST soi 4;. <r." <br /> 5.Generators Name and Mailing Address Generator's Site Address(if different than mailing address) <br /> 161, <br /> Generator'sPhone,-M Ui 44L 4-4;A <br /> 6.Transporter t Company Name U.S.EPA ID Number <br /> N "":F.f <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 /> +9r....iti9 '-es s.:odd i <.��'.�r,xew ":.£i� f.��♦3r �i�::.l a <br /> Fadid'SPhone <br /> - -- -- _ 10.Containers 11.Total 12.Unit <br /> g.Waste Shipping Name and Description <br /> No. Type Quantity W0Vol. <br /> ¢ 1. e <br /> a4ix 'k*4I$ re+v:Ova r;frCA t$espy `f is=?r x, x6Le. •.z } <br /> M <br /> C'1 2l <br /> f le, <br /> 4 <br /> 13-Special Handling Instructions and Additicmai Intormalion <br /> 14.GENERATOR'81OFFEROR'S CERTIFICATION:I hereby declare that the contents of this consignment are fully and accurately described above by the proper shipping name,and are classified,packaged. <br /> marked and labeledrplacarded.and are in all respects in proper condition for transport according io applicable intemabonal and national governmental regulations. <br /> Genera[orsOlferorsPriwertTypedName - V Signature Month Day Year <br /> _r 15,International Shipments 1 <br /> F J Import to U.S. ❑Etipo+1 from U.S. Port of entry:erut=—_ <br /> Trans der S alure tar ex ds and Date leavin U.S.: <br /> a <br /> cc 16 Transporlur Acknowledgment of Receipt cf Materials <br /> W <br /> Transporter 1 PrintedlTyped Name Signature Month day Year <br /> 0 <br /> CL <br /> 4 Transpurter2 Printed/Typed Narne Signature Month Day Year <br /> 17 Discrepancy <br /> 17a.Discrepancy Indication Spacer+ <br /> LlQuan Type ❑Residua ❑Partial Ra)act[on ❑Futf Rejetiktro <br /> t} <br /> � 1 Manifest Rr eferarce Number: <br /> s- 17b.Altemale Facility(or Genarator) U.S.EPA ID Number <br /> rai Facility's Phone: � '►✓ � 4r ; ', <br /> 17c.Signature of Alternate Facility(or Generator) D' " Month Day Year <br /> a <br /> r1 <br /> +sr <br /> w <br /> t] <br /> 18 Designated Facility Owner or Operator Certification of receipt of materials covered by the manitest except as noted In Item 17a <br /> PdntedrTyped Name Signalure Month Day Year <br /> I <br /> 169-BLC-0 6 10498(Rev.9109) GAENERAT'O 'SISHIPPER'S INITIAL. COPY <br /> I <br />