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ih � <br /> 3;HRZARDOUSi.Generator IR N 0age 1-d 3.Emergexy Response Phone '4.�Tracking Num _ <br /> 1NANIFF.ST ti A L 1} 0 $ Y $ d24-90100 G SURM Q~r T 1. bk <br /> S.Generators Name and Mattir Generefora Ste Address(K different than manTrig address)) <br /> Generatoes phone: 814-44n I <br /> a.Transporter 1 coup"Rame. - - U.S.EPA ID Number — -- <br /> MEWUW ENV1RONMEM'k x 1l. _ C A I 0 A 1 7 1 0 1 7 <br /> 7-Transporter 2 Comparhy Name U.S.EPA Ip Number <br /> W LDWPE REWWRY SYSTEM , — CAR 0 0 1 7 5 4 2 2 <br /> B Def ftF#&pttVd!rite Address f U.S�EPA[D Number <br /> ZM E IM ST <br /> YUMA AZ 85365-1901 ' r <br /> -Fadi sem: 928 344-99281 II A Z 0 g 0 5 1 5 9 2 4 s <br /> 9 Waste Shipping Name and Description 10'Containers 11.TOW � 12.Unk � k <br /> _ Ho. Type Quantity WtNol. <br /> I <br /> DIMS ATF,LKXAD(NEUTRALIZING T <br /> a <br /> ' 3. i <br /> 4. <br /> 13. <br /> 14,GENERATOR SIOFFEROR'S COMFiCATION'I,here6y dedam that the=ft is of this oo sOwneni are fatly and destafxd above by the proper shipping name,and are dassffied,padmye� <br /> marked and arxh are in al respects In pmper corMitfonlor transport amodng to sppiicabfa I and ratland govermhental regulations. <br /> Genet11Aa6ors70te lam " �- t m pay <br /> 1 I f I Manfh , Year. <br /> .,a <br /> -skr <br /> 1 . _ Az� <br /> 0 import to U.S. ❑Egod from U.S. Pod of enbylexik„-.- <br /> Trwmaer tum!,forepx""i: — Date.leaft U.S.: <br /> 16.Transporter AdmMedgmerd d Receipt of Materiah <br /> Transporter 1 PdnhdTyped Name R Y� 5ignatura,.= * Month, Day Year' <br /> Transporter2PdnWTypedName - Signature - ~- Month -Day Year <br /> 17.Discmpanq - <br /> 17a.Discrepant Indcatlm space ❑ ❑Ty" ❑Residue — <br /> ❑PertW Rejection ❑F,1 R*d, <br /> Mardfesl Reference Number. <br /> 17b.Alternate Fadity 1,w Ceneratwl U.S.EPA IO Nhanber <br /> sL FsaWs Phone: <br /> 17c.Sig mhn of Memo Fw*hty(or Generator) - r— <br /> Mardh Det Yea <br /> 1 B Dsslg mW Facky Owner or Operator.'CedsCration of mce£pt of materials covered by the mrtifest emo as mated in Ithm 17a <br /> s Pdnledffyped Name Slgrature T Month Day Year <br /> 169-BLC-05 11977(Rev.9/09) O GENERATOR'S/SHIPPER'S INITIAL COPY <br />