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08/02/2018 10:39 (FAX) P.064/065 <br />?� G'4LG"', fih i'.:eiy!. ':�,.1 :"y:•. M d 75.56:i <br />ii,26 Pias. .•,,yzd C'�,. "Pif"I <br />Can- watun•: 5620:x_­iM . Cres_Fs:: 50960 Ww <br />1 Q Of -t: 7'14120 LB'.l <br />qtr L i £f'k'�?to�s'c>lcta d� '•z .r . lig? <br />?rsa...-......_,.....�.._._Rate T_M^iv%-'Qumz .. <br />VJt�ul7Ti"tacxclW- yrl°xu, e•,rt ;fir iti.:>>.: i 4 _.;�. ')' y5.aa5 r.1? .70 <br />18, Designated Fadity Owner or Opamiur, Cedlflceson of rtcelpl of matadels covered by the mardiresl except as naled In Item 17a <br />Prhijdrryped Name, <br />- � t.:•i �:.>;,1 ,:1,".� ' ::� ;r •.. / Month Day Year <br />O -BLS -C 5 11970 (Reny, 9m) <br />TRANSPORTER #1 <br />IUD <br />M3 -1n RAN ,., PHnb.r.1 nn mcyelr'•Cl plipor <br />VIE - <br />HEALTH DEPAPTME. <br />14, OENERATORIWFFRRG" CHMPICATION: I hereby declare Mut the contents of this o nooment are 1uoy and bwurutaly descdbed above by the proper a #kV Mama, and art deeaihed, packaged, <br />Marked end Iaheledlpiacardad, end an In IN resptots In proper condition far Irarrepon Wording to appkos k0ml#60rul Arid rtaknal yovem m of rtgA ions. <br />Genamt-cevDff&mt'$ Primeeyped Nems <br />SlgnMure r / Month Day Year <br />15. intematlona! Shlpmenie <br />❑ Import tD U.S. <br />❑ Export from U.S. Port <br />T rter S lure far ex rte onl <br />d erd"xle <br />Date be U.S,; <br />r¢ ie. Transporter AdMOWledgmenf of Poalpl of Materiels <br />17anaporttr 1 Priv Wyptd Name <br />i <br />--j"/ <br />Signature ! ' <br />t Month Day Year <br />Transporter 2 PIy* Name <br />- <br />Stun " <br />Mpdh Day Year <br />17, DWmpmy <br />17a, Oisoropen�y lndloetion t3paca <br />❑ ouemlty <br />�-1 <br />U type ❑ Residue <br />❑ ftrw iiow, ❑ Full Rejecllon <br />17b. Attemate FieWly (or Generator) <br />Manifest ReNrenee Number. <br />U.S. EPA lO Number <br />i FaLillys Phone: <br />I M. Signature of Altemate Fodfly (or Genemlor) <br />Month pay Year <br />18, Designated Fadity Owner or Opamiur, Cedlflceson of rtcelpl of matadels covered by the mardiresl except as naled In Item 17a <br />Prhijdrryped Name, <br />- � t.:•i �:.>;,1 ,:1,".� ' ::� ;r •.. / Month Day Year <br />O -BLS -C 5 11970 (Reny, 9m) <br />TRANSPORTER #1 <br />