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J � <br /> NON-HA7.ARDOUS 1.Generator ID Number 2.P e 1 of 3.Emerge R sponse Phone Waste c g umber <br /> WASTE MANIFEST — r goy <br /> S.G �orme and Mail )Addrass Gene rp= rdres iffe 'tth 3 iaddress <br /> 061 <br /> Gene s Phone: �a��C ' ��' +' ��� ��� i 1•�+C' iJ�"V W <br /> fi.Tran o r .Compan U.S.EPA ID Number <br /> 7.Transp rter L Company Name U.S.EPA ID Number <br /> B.Desi na e�Nam Ad r / U.S.EPA ID Number <br /> Facili hone:)qI0 W �� ✓►� -! <br /> 9.Waste Shipping Name and Description 10,Containers 11,Total 12.Unit <br /> No. Type Quantity Wt.Nol. <br /> a 1cc <br /> AVA) i�e X10 O <br /> z2. <br /> 3. <br /> 4. <br /> 13.Special Handling Instructio/ns and Additional Information <br /> krv� a- 1 °16 <br /> 14.GENERATOR'SfOFFEROR'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 Iabeledrplacarded,and are in all respects in proper condition for transport according to applicable international and nalIonal governmental regulations. <br /> Genera Offeyped rsPrin Signa Mc O2y Year <br /> I ro 04 <br /> 3 <br /> 15.Into tional Shipments <br /> import to U.S. Export from U.S. Pori of entrylexit: <br /> Transporter Signature far ex orfs only): Data Wving U.S.: <br /> M 16.Transporter Acknowledgment of Receipt of Materials <br /> W <br /> 0 Tranre r i Pm a� Signature Year <br /> G 'Jr- <br /> N 2�z_" 1 11� <br /> z Transporter 2 PrintedTypsd Name Signature Vonlh Day ear <br /> 17.Discrepancy <br /> 17a.Discrepancy indication Space Quantity ❑Type ❑Residue ❑Partial Rejection ❑Full Rejeclion <br /> Manifest Reference Number: <br /> r 17b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> J <br /> V <br /> ra Facility's Phone: <br /> W 17c.Signature of Alternate Facility(or Generator) Month Day Year <br /> a <br /> z <br /> S2 <br /> N <br /> W <br /> Q <br /> 18.Designated Facility Owner or Operator:CertiFicaioon .0als covered by the manifest except as noted in ly4l7a <br /> Pdd� <br /> nteyped Name Signature h ar <br /> J� <br /> 169-BLC-0 5 11977{Rev.9109} DESIGNATED FACILITY O GENERATOR <br />