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NON-HAZARDOUS 1.Generator ID Number 2,Page 1 of 3.Emergency Response Phone 4.Was Trac ;g0ber 0? <br /> WASTE MANIFEST Q❑ — 30 <br /> 5.GFo7rrj,and Jelling Address Generator's Site Ad ( lShanLna res <br /> Gerferalo�sPh I � �' ' I � gf2zi �I"�jI "Aj <br /> S.Trans ny a ` U.S.EPA ID Number <br /> 7.Transportef 2 C4PAY Nanng U.S.EPA ID Number <br /> S.Clesignad Fa kity Name an Site Address ti� U.S.EPR!D Number <br /> Fac s ne POVIR <br /> 9.Waste Shipping Name and Description 14.Cord Iners 11.Total 12.Unit <br /> No. Type Quantity Wt,w <br /> 1. <br /> cca <br /> _k/- <br /> 2.2. <br /> 3. <br /> 4. <br /> 13.Special Handling Instructions and Adddifionai Information <br /> 56i Iq -J0a% 1Jo. fit —.?,(fir4,tw 0-1 ,010 <br /> + 4zO <br /> 14.GENERATOR'SIOFFEROR'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 IabeleTplacarded,and are in all respects in propyr condition for transport a000rding to applica9knlematonak an national govemmental regulations. <br /> Ge to mr yped Sig Month Qay year <br /> r4rou/ A w� <br /> F 15.International Shipments Import to U.S. ❑Export from U.S. Port of entry/exit: <br /> Transporlar Signature for exports on : Date leaving U.S.: <br /> w IB.Transporter Acknowledgment of Receipt of Materials <br /> Transporter PrntedTypedNa1me ,r Signature Ma <br /> nsporn I ear <br /> 11,v � <br /> a Transporler2 Printedlfyped Name Signature Month Day Year <br /> ccF <br /> 17.Discrepancy <br /> 17a.Discrepancy Indication Space e <br /> ❑Quantity ❑Type ❑Residue L1 Partial Rejection 1:1 Full Rejection <br /> Manifest Reference Number: <br /> r 171.Alternate Facility[or Generator] U.S.EPA ID Number <br /> J <br /> U <br /> rai Facility's Phone: <br /> W 17c.Signalure of Alternate Facility for Generator) Month Day Year <br /> a <br /> x <br /> rA <br /> W <br /> fl <br /> 18.Designated Facility Owner or Operator:Cendi;ratio of ipt of materials covered by the manifest except as noted in Item 17a <br /> If Printed/Typed Name Signature M th Y <br /> 169-BLC-0 5 11977(Rev.9109) DESIGNATED FACILItYTO GENERATOR <br />