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NON-HAZARDOUS 1.Generator IR Number 2.Page 1 of 3.Emergency Response Phone 4.Wowq,�P—,= <br /> r <br /> WASTE MANIFEST �} S—4 D0 — D3❑5 <br /> 5.Generator and ailing dress Generator's Site Address Sif diff ent than mailing adds <br /> �• ���� `��� V1'v �' Olt' <br /> JIVO_�f + <br /> G rotor's Phone: <br /> 6-Transportpr IrNa �+ U.S-EPA ID Number <br /> 7.Transporter 2 C pang Name U.S.EPA ID Number <br /> 8.Desi � if NamSite eA s�,_�� U.S.EPA ID Number <br /> Fac l' 's PPha : PfV�� <br /> 9.Waste Shipping Name and Description 10.Containers 11.Total 12.Unit <br /> No, Type Quantity Wt.Nol. <br /> it <br /> 9 � rtr <br /> ° <br /> 3- <br /> 4. <br /> 13,Special Handling Instructions Wditional Information AJO., 6 �61 / I r� <br /> 14.GENERATOR'SIQFFEROR'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 labeledfplacar d,and are in all respects in proper condition f r transport according to applicable intypflional and nallonal ovemmental regulations. <br /> Gen t /7P d Namur / �� Signatu l l�fari ly Year <br /> ..r 15.Inter i nal Shipments 1 120 <br /> �Il�'rJ✓ <br /> Impart to U.S. Export from U-S. Port of entrylexit; <br /> x <br /> Transporter Si nature for exports onl : Date leaving U.S,: <br /> ir 16.Transporter Acknowledgment of Receipt of Materials <br /> LU <br /> Transporter 1 Prinled`Typed Name Signature Month D y Yea <br /> 0. 0' hl"AiT <br /> w l <br /> N <br /> 2¢ <br /> Transpo&(l PfrnfedfYiped Name Signature Month Day Year <br /> 17-Discrepancy <br /> 17a.Discrepancy Indication Space ❑Quantity ❑Type ❑Residue ❑Partial Rejection ❑Full Rejection <br /> Manifest Reference Number: <br /> 171a.Alternate Facility(or Generator) U.S.EPA IA Number <br /> J_ <br /> V <br /> rai Facility's Phone: <br /> Ld 17c-Signalure of Alternate Facility(or Generator) Month Day Year <br /> G7 <br /> yW <br /> D <br /> 18,Designated Facility Owner or Operator.Cerlificalianjkoceipt of materials covered by the manifest except as noted in Item 17a <br /> PrintedrFyped Name Signator M <br /> 169-BLC-05 11977(Rev.9109) DESIGNATED FACILITY 10 GENERATOR <br />