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Ig. Waste SNpping Name and Description <br />10, Containers 11. Total 12 urn <br />11 <br />No. Type Quantity WINol.. <br />11 <br />.O° <br />WM\A <br />Z2., , <br />W r <br />13. Special Handrng Irisinnctions and Additional Information <br />14. GENERATOR'SIOFFEAOR'S CERTIFICATION; I hereby declare that the contents of hs consignment are Uly and accurately described above by the proper shipping name, and are classN!ed, packaged, <br />marked and labeledlplacaided, and are in eA respects In proper ccn0lllon fa.transporl according to applIcabie intemalional and nabonalpcvemmantal regulations. <br />GerieratcesUames Pdnted/Typed Name <br />Signature <br />Monlry Day Year <br />d <br />-.I 15. ln1anwUonal Sth* eats <br />Impart to U.S.AR <br />❑ Export from U.S. Port of enlry/er t <br />— Transporter Sl nature ler ex Ifs only): <br />- - Data Imt . ig U.S.: <br />¢ 16. Transporter Acknowledgment otflecelptofMatwlals <br />T . rter 1 PrintefTyped Name i <br />0 1 <br />$Ipnatu f <br />Month Year <br />Web14) t1 <br />a TnL*dFta?'21PriAhWTypedNama <br />, <br />VSignatu <br />nth Do or <br />17. Discrepancy <br />17e. Dlscrepar>cy.4dcation Space ❑ Quantity <br />❑ Type ❑ Residue ❑ Partial Refection <br />❑ FJI Re)ecllon <br />Manifest Reference Number. <br />17b. ArterreFadlky (or Generator) <br />x U.S. EPA ID Nunber <br />U <br />U. Fad ilysPhono: <br />17c Signelum of ARemate Facility (or Generator) <br />d <br />Month Day Year <br />0`11 � y{5��f f .1@a 13 'K i � ` •C? `' 1 .: t �'k 1! tY�+• t�,K <br />Il �1��1'C'rl� � <br />M!�'7i. iiiiii ,"1 <br />� <br />,Yt.4.r"•S.+r, 5 ! '�- �:G� <br />�l �' �t�i 'B. '� W ��ulf f yi{�y�� R 3 IV �h tN'h %r <br />�� .� <br />:y.t>OWn or <br />18. oeslgnated Fac' siner to C <br />WarraargAl�l{ca�Oon Of recalpl 01 -materials covered by the mardlest except sig noted In Rom 17e <br />1 ypedNarne/� <br />/ <br />i69 -BLS -C 5 11979 Mev 91091 <br />TRANSPORTER #1 <br />