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8 <br /> PlrN <br /> int or type.(Form designed for use on elite(12-pllch)typewriter) <br /> DN-RAZARDOUS 1.Generator ID Number 2 Page 1 D' I Emergency Response Phone 4.Waste Tracking Number <br /> AS <br /> TEE MANIFEST <br /> 5,Generator's Name and Mailing Address Generalor's Site Address(if different than mailing address) <br /> Generator's Phone, <br /> u, ansparter 1 Company Name U.S.EPA ID Number <br /> ?.Transporter 2 CoirpEny Name U.S.EPA Ip Numher <br /> a.Designates Faculty Name and Sile Address U.S.EPA 1D Number <br /> Facility's Phone: <br /> ga 9b.U.S,DOT Description Orciuding Proper Shipping Name,Hazard Class,ID Number, ii).C(ntski.ers 1.Total 12.Unit <br /> HM and Pac4ing Group(if any) - _ No Type Quantity Wlivol. <br /> 1 . <br /> O .. <br /> LU <br /> r_u <br /> M r. <br /> LU <br /> C7 <br /> 3. <br /> `3.Special Handling Ins!ructians and Additional Information <br /> 14. GENERATOR'S CERTIFICATION: I certify the materials described above on this manifest are not suhjecl tp federal regulalions for reporting proper disposal of Hazardous b"daste. <br /> Generat,r'slOffercr's Printedrryped Name Signature Month Day Year <br /> J 15.international Shipments <br /> E- ❑Import to U.S. ❑Export from lJ S_ Port of entrylexit: <br /> Transporter signature ifor exports orly}: Dale leaving U.3.: <br /> � 16,TranspDrter AcknoH4edgrnefit of Receipt of Materials <br /> L _ <br /> Transposer 1 Printed d Name Signatur / Month Day Year <br /> a i G; ❑ci-�Fi,� v 1j f- <br /> Transpar:er2N,cne Sigr re Month Day Year <br /> s- <br /> 17 Discrepancy <br /> 17a.Discrepancy Indication Space ❑ quantity ❑Type ❑Residue ❑Partial Rejection ❑Full Rejeclicn <br /> Manifest Re`erence Number <br /> ".71h,AI!arrnatn Facility(or Generator) U.5_EPA ID Number <br /> J <br /> U <br /> La- Facility's Phone: <br /> w 17c.Signature of Alternate Facility for Genaratorl Month Day Year <br /> Q <br /> O <br /> w <br /> O <br /> 13 Deslgnnied Facility Owner or Operator.Certification of receipt of materials covered by the manifest except as noted in Iti,nm 1�n <br /> Prnted;Typed Name Signature Month Day Year <br /> 6-NHM-C-C-11 <br /> 6-GENERATOR'S INITIAL COPY <br />