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f <br /> NDN-HAZARDOUS 1.Generator ID Number 2.Page 1 of 3.Emergency Response Phone 4.Waste Tracking Number <br /> WASTE MANIFEST <br /> 9OC ti:i NA,25cq <br /> 5.Generators Name and Mailing Address Generators Site Address(it different than mailing address) <br /> iflf`,t :T()t - <br /> l , , f1,2 I 45 C;i R. 7KE P a,t; ; <br /> I „•kT=ro. CIP <br /> ,tiC;f';T N,CA >0,5 <br /> Generator's Phone: <br /> 6.Transporter I Company Name U.S.EPA ID Number c <br /> Et.�ll,ti%?I°,FaE�1T,.LL Gl.SFIi , I!aC „r0001?w'�b;'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 /> 180 WES—f f.'OINTE A,i71~I (JE CAD96..&-: E:i <br /> c <br /> Facilit's Phone: 8`0"09''43;' <br /> 9.Waste Shipping Name and Description 10.Containers 11.Total 12.Unit <br /> No. Type Quantity Wt.Not. <br /> 1' NON lila R P;tr<1J 1=11M? (E SOUD ��11.G(7''71 4v'­j i C)Pi•9 / (; <br /> cck� <br /> 0 <br /> w <br /> 2 2 <br /> ru . <br /> c� <br /> 4' <br /> WE <br /> 13. Special Handling Instructions and Additional Information <br /> E'';:,011 C i 7!'N3 ,4 10 12 3 0 0 8 �i'JvC6i�'� WEAR ,e PPP01`zFRIA.Try"PPIZ <br /> 14.GENERATOR'S10FFEROR'S CERTIFICATION:t here declare that the contents of this consignment are full and accurately described above b the ershi in name,and are classified, <br /> by 9 Y Y Y Prof PP 9 packaged, <br /> marked and labeled/placarded,and are In all respects in proper condition for transport according to applicable International and national governmental regulations. <br /> Generator's/Offeror's Prinledi7yped Name Signaluie Month Day Year <br /> �r sly' �J � <br /> 15.International Shipments <br /> z11Importto U.S. ❑Export from U.S. Port of entry/exit: <br /> Transporter Signature for expos orgy): Date leavi U.S.: <br /> w 16.Transporter Acknowledgment of Receipt of Materials <br /> Transporter 1 PrintedfTyped Name Signature Month Day Year <br /> En <br /> 4 Transporter 2 PrintedrTyped Na Signature �. Month Day Year <br /> h �`V <br /> 17.Discrepancy <br /> ( <br /> 17a.Discrepancy Indication Space <br /> El Quantity Quantity El Type El Residue ❑Partial Rejection Full R ejecticn <br /> Manifest Reference Number: <br /> 17b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> v � <br /> LL Facildys Phone: P <br /> w 17c.Signalure of Alternate Facility(or Generator) Month Day Year a <br /> z <br /> 0 <br /> ti <br /> w ; <br /> 18.Designated Facility Owner or Opera r.Certification of receipt of materials covered by the manifest except as noted in Item 17a <br /> Printed/Typed Name Signature Month Day Year <br /> i 7 rr f <br /> 169-BLC-0 5 11977(Rev.91 ) DESIGNATED FAOIL TY '6t=p GENERATOR <br /> I <br />