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40N HAZAFOOus 1 Generator 11)Number 2 Page 1ot B.Emergency Response Phone 4.Waste Tracking Number <br /> WASTE VANIFEST <br /> Address <br /> _ — <br /> S Gena Generalor's Site Address(d ddrerenl than marling-address) <br /> Generators Phone - �- <br /> 6.Tia Spoiler 1 Ca US EPA ID Numter <br /> ---- - -- ----- ----- - ERA-7 Transporter 2 Company Name -- -----_-- I U.S.FPA ID Nu—mtar-- <br /> 1�- <br /> 9 Desgna!ed Facility Name and Sde Address U.S EPA ID Number <br /> I <br /> Facri, s Phone <br /> 9 Waste Shipping Name and Description 10.Containers it.Total 12.Unit <br /> No Type Quantity WtNol. <br /> 1 1 - <br /> Q <br /> 2 2 <br /> Lu <br /> CD <br /> 3 <br /> 4. <br /> 13,Special Handling Inst uctions and Additional Information <br /> 14.GENERATOR'S/OFFEROR'S CERTIFICATION:I hereby declare that the contents of this consignment are fully and accurately described above by the proper shipping name,and are dasslied,packaged. <br /> marked and labeled placarded,and are in all respects in proper condition for transport according to applicable <br /> international and national governmental regulations. Month Day Year <br /> Generators Ofiercl Printed'Typed Name <br /> exAl <br /> 15.International Shipments ❑Import to U.S. El Expo t from U.S. Pott of leavientryng <br /> U <br /> Dale levin US <br /> .S.: � <br /> Trans iter Si nature for ex its Tlvi' -- <br /> cc 16.Transporter Acknowledgment of Receipt of Materials !�Icrih Cay Year <br /> Signature 1 I <br /> Transporter 1 Printed,Typed Name I — i <br /> cc --- A!cnm 034 Y-ar <br /> a Signature <br /> QTransporter 2 PnntedTyped Name — - <br /> 17 D+screpancy - -- ❑FLd Re,ectu <br /> ❑T Residue ❑Partial Re,ecncn <br /> 17a.D screpa c IMrcahon Space Quantity " r' <br /> hdanitest Reference Number U,S.EPA ID Number <br /> 17b.Altemate Faauty for Generator) <br /> 7 I tkrth Day II Year <br /> 4 FadNb <br /> i7t. e d mate Ph": �' <br /> Facility(or Generator) ENV` <br /> � _ <br /> Qu ------- I — <br /> V <br /> O --- <br /> s t the m,trdest except as noted in Item 17a <br /> w(1ralOr GeAdreat+on of r00aipl of rnalona'r, . " --_ _ I <br /> 18.[ibrr°pndltd f;Kdey ter Signature _� _- <br /> PrintedfTypollarne ----�_— - — rENERATOR'S.fSti�PPER'S INITIAL GCPK <br /> 169-BLS-C 6 10407(Rev.9/09) <br />