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IFWASTE <br /> E'll 1DOUS 1.Generator ID Number �Page]�:�2. 3. merg�Respon:e Phone 4.Waste Tracking Number <br /> ML �d�3 sName and Mailing Address / era oress(rf different than mailing address) <br /> . <br /> S Phhone:one: <br /> S4 e-kAm C43�dJ <br /> nerator' <br /> 6.Transporter i Company Name <br /> U.S.EPA ID Number <br /> 7.Transporter 2 Company Name <br /> U.S.EPA ID Number <br /> 8.Designated Facility Name and Site Address 1 CuLee•S ,S eri4 ets T z, U.S.EPA ID Number <br /> i rii 's}hone: �1��*S '�-[•E=�Li� e4 <br /> . <br /> 7 eEIA <br /> 1 9 Waste Shipping Name and Descrfption 10.Containers 11,Total 12.Unit <br /> 1 No. Type Quantity Wt.Nol. <br /> W <br /> 01 [ S70 P <br /> W 2, <br /> IIr C3 <br /> I ' <br /> I - <br /> 4 <br /> . I <br /> 1 13 Special Handling Instructions and Ad 'tional Information <br /> Vial <br /> I <br /> ial offs 5��+ +Ex S[A �ttu <br /> 14.GENERATOR'S/OFFEROR'S CERTIFICATION:I hereby declare that the contents of this consignment are fully and accurately described above by the proper shipping name,and are classified,packaged, <br /> marked and labeled/placarded,and are in all respects in proper condition for transport according to applicable inlematronal and national governmental regulations. r <br /> Generator's/Offerors Printed/Typed Name Signature <br /> M nth Day Year � <br /> � . <br /> � 15 Inter nafivnal Shipments <br /> ❑Import to U.S. ❑Export from U.S. Po of enirylexit: <br /> 2 Trans orter Si nature for ex oris onl : <br /> cc W 16.Transporte eknowledgment of Receipt of Materials ate la,'n U.S.: <br /> Transporter 1 P ted/Ty, d a Si allure <br /> q p , �� Month Day Year <br /> Z¢ Transporter 2 PrintedlTyped Name Signatu 1 <br /> :F Month Day Year <br /> 1 17.Discrepancy <br /> 17a.Discrepancy Indication Space <br /> ❑Quantity ❑Type ❑Residue ❑Partial Rejection <br /> 1 El Full Rejection <br /> I <br /> 1 17b.Alternate Facility(or Generator} Manliest Reference Number. <br /> :3 U.S.EPA ID Number <br /> v <br /> I Facility's Phone: <br /> w 17c.Signature of Alternate Facility{or Generator} <br /> z Month Day Year <br /> C9 <br /> Lu <br /> a <br /> i 18 Designated Facility Owner or Operator Certification of receipt of materals covered by the manifest except as noted in item 17a <br /> Prinled/Typed N Signature <br /> Month Day Y € <br /> 169-BLC-0 6 10498(Rev.9109) DESIGNATED FACIL TYTO GEN BATOR{ <br />