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NON-HAZARDOUS 1.Generator ID Number 2,Page 1 of 3.Emergency Response Phone 4.W800 Track) Number �a <br /> WASTE MANIFEST r At7�5 --03 Q5 �lf� <br /> 5.��'�t�IgMe� Ma' a Address Generato>'s Site Addre��diff t than aiEi�ddress} _ S� <br /> pne;ops <br /> nSV��'IVGPho e V�IA"il <br /> 6.Transpo 1 Cqm Name �• U.S.EPA ED Number <br /> 7.Transporter 2 Company Warri U.S.EPA ID Number <br /> I$.°°q�si naigd Fa iry Name an its �D U.S.EPA ID Number <br /> Fa�ili 's Phone: � yo'� f l7 1 <br /> 9.Waste Shipping Name and Description I 10.Containers 11.low 12.Unit <br /> No. Type Quantity Wt.Nol, <br /> r� (S6 1 <br /> ir <br /> 2. <br /> 3. <br /> 4. <br /> 13.Special Handling Instructions and A ditional Information <br /> soil -Jia A)D_ L- 26 <br /> 0-/ °, p1bafW w)v- dozo <br /> 14.GENE RATOR'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 labeled/placarded,and are in all respects in proper condition for transport according to applicable international and na no governmental regulations. <br /> Gen7in— <br /> 'R,, )ped Nam _7 ' Sign �' r� M h D y Ye <br /> ff [/Jl��/J -9f f/ <br /> -.r 15.Intemational Shipments <br /> Import to U.S. Export from U.S. Port of entrylexit: <br /> Transporter Signature for exports only): Date leavin <br /> w 16.Transporter Acknowledgment of Receipt of Materials <br /> Tran Pfint Name , �� Signature )♦tooth pay Year <br /> w pLL U 1 <br /> a Transporter 2 Pdntedliypad Name signature Month Day Year <br /> fr_ <br /> 17.Discrepancy <br /> 17a.Discrepancy Indication Space ❑Quantity ❑Type ❑Residue ❑Partial Rejection ❑Full Rejection <br /> Manifest Reference Number. <br /> 17b.Alternate Facility tar Generator) U.S.EPA 1D Number <br /> UJr� <br /> rai Facility's Phone: <br /> W 17c.Signature of Alternate Facility for Generator) Month Day Year <br /> a <br /> x <br /> N <br /> Y3 <br /> C <br /> 18.Designated Facility Owner or Operat lfication of receipt of materials covered by the manifest except as noted in Item 17a <br /> Printed+Typed Name /(x Signature n <br /> 169-BLC-0 5 11977(Raw DESIGNATED FACILITY TO GENERATOR <br />