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NON-HAZAFIi]t?U5 i.Generator ID Number 2.Page 1 of 3.Emergency Response Phone 4.Was Tr in Number <br /> WASTE MANIFEST �'L� C1 (50S) (400- 03o� <br /> 5.Generator' me an Mail[g Address Generator s Site Add ss{if r rant t an m ling address <br /> Ger> rr 'rs one: ■+ u�� 'k, kahQ 1 <br /> 6.Transpo;y!qArU.S.EPA i0 Number <br /> R <br /> 7,Transporter 2 915mpany Name U.S.EPA ID Number <br /> 8.Desi nye a /�Nay�_�nd S]te Ild�'y�^� U.S.EPA Ea Number <br /> wl <br /> Foci 's Phone: + D�� 1 S✓, V ! <br /> 9.Waste Shipping Name and Description 1o.Containers 11.Total 12.Unit <br /> No. Type Quantity Wt.NoI. <br /> A1. <br /> a <br /> ' I f <br /> a 0 <br /> rr <br /> ur <br /> z 2. <br /> W <br /> C7 <br /> 3. <br /> 4, <br /> 13.Special HandPing Instructions and Ad6tio al Information l <br /> 0 <br /> �&! a, <br /> 14.GENERATOR'S10FFEROR'S CERTIFICATtON: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 labele placarded,and are in all respects in p ropqr condition for transport according to applicable international anj national governmental regulations. <br /> Ge or' 'tedrTyp af�e !3 z, I Si t s �� M nth � Yea <br /> M� <br /> J 15.Inte ationat Shi laments C/�m ort to U.S. "IV <br /> Import to U.SExport from U.S. Pvrt of enlrylextib <br /> Transporter Signature lar ax rte only): Date leaving U.S.; <br /> rt 16.Transporter Acknowledgment of Receipt of Materials <br /> LU <br /> Transporter 1 PrintedlFypearn; Signature ply Year <br /> O RD <br /> N <br /> Q 14 <br /> Transporter 2 P n yped Name Signature Month Day Year <br /> 17.OisCrepancy <br /> 17a.Discrepancy Indication Space ❑Quantity ❑Type ❑Residue ❑Partial Rejection <br /> ❑Full Rejection <br /> Manifest Reference Number: <br /> 17b.Alternate Fad€ity(or Generator) U.S.EPA 10 Number <br /> J_ <br /> V <br /> ua. Facility's Phone: <br /> W 17c.Signature of ARemate Fachity(or Generator) Month Day Year <br /> ti <br /> z <br /> C7 <br /> N <br /> LLr <br /> G <br /> 16.Designated Facility Owner or Operator:Certilkton of re of materials covered by the manifest except as noteg in Item 17a <br /> Printed'Typed Name Signature ont ❑ <br /> 169-BLC-0 5 11977(Rev.9109) DESIGNATED FACILITY T GENERATOR <br />