Laserfiche WebLink
NONHAZARDOUS 1.Generator ID Number 2.Page f of 'emergency Response Phone 4.YYasta Tmcktng Number <br /> WASTE MANIFEST <br /> 5.Generator's Name and Mailing Address Generator's Site Address(if different than mailing address) <br /> 7�t5CVX Y-EleVe - -..-.;-,-e#205324627 <br /> Daia5 t 711 =n C 5207 USA <br /> C1r7kIr7G.T'.r l`1i�1 1.J:�1-., r=_+_1�:.1�r3,��, � 4 <br /> Generalor's Phone: <br /> I <br /> 6.Transporter 1 Company Name U.S.EPA ID Number <br /> 7.Transporter 2 Company Name U.S,EPA ID Number <br /> 8.Designated Facility Name and Site Address (Ti It 10�, U.EPA IDN tuber <br /> k <br /> 110 �Jrpott Rd, . <br /> Rite-ls1a.GA 93571 USP <br /> Facility's Phone: i <br /> 9.Waste Shipping Name and Description 10.Containers 11.Total 12.Unit <br /> No. Type Quantity Wt.lUol. <br /> Ix <br /> 0 <br /> i <br /> W t <br /> 2• <br /> LU <br /> 3. <br /> 4. <br /> 1 <br /> 13.Special Handling Instructions and Additional Information <br /> I <br /> I <br /> 14.GENERATOR'SIOFFEROR'S CERTIFICATION:1 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 international and national governmental regulations. <br /> Generalor's/Offeror's Printed/Typed Name Signature Month Day Year <br /> If <br /> 15.International Shipments ❑Impart to U.S. ❑Export from U.S. Port of entrylexit: <br /> Transporter Si nature for exports only): Date leaving U.S.: <br /> ¢ 16.Transporter Acknowledgment of Receipt of Materiai <br /> w ^ <br /> t Transporter 1 PrintedlTyped N n1v Signature ' F h Day Yeat'- <br /> cc � %' f <br /> cn ¢ /� <br /> Q Transporter 2 PrintedlTyped am Signature Month Day Year <br /> F <br /> 17-Discrepancy <br /> 17a.Discrepancy Indication Space <br /> ❑Quantity ❑Type ❑Residue ❑Partial Rejection L1 Full Rejection <br /> Manifest Reference Number: <br /> 17b.Alternate Facility(or Generators U.S.EPA U Number <br /> U <br /> Facility's Phone: <br /> Lu 17c.Signature of Alternate Facility(or Generator) Month Day Year <br /> Ul <br /> u¢ <br /> 18.Designated Fa6lity Owner or Operator:Certiticalion of receipt of materials covered by the manifest except as noted in Item 17a <br /> PrintedlTyped Name Signature Month Day Year <br /> �7?zr�� F���� h�1•� ���, 4�l 1 � .LCA <br /> 169-BLC-0 5 11977(Rev.9109) DESIGNATED FACILITY'S COPY <br />