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NON 1.Generator I Number 2.Rage 1 of 8 Emergency Response Phone 4,Was Tr ckfng ber <br /> WASTE MANIFEST l 1 cr7�j�'!o0"0 305 d� <br /> 5.Generator's Name and Mailing Address Generator's Site Address(if different than mailing address) <br /> 7-6(_Gv� -76� sTLl-ie� "U 0 av63 <br /> Generator's Phone: <br /> 6.Trarnsporte ❑ a U.S.EPA ID Number <br /> 7.Transparterl C mpany Nam U.S.EPA ID Number <br /> 8.Designated Facility Name and Site Address _ U,S.EPA 1D Number <br /> W AST �C7I�h l�'teC?►�s��� � t�L$ l,�,n11aY-1 G!. l <br /> ?<ww J4(L4_5 �� 5uIjk JJ Ci '7k6867 <br /> Facil' s Phone: <br /> 9.Waste Shipping Name and Description 14.Containers 11.Total 12.Unit <br /> No. Type Quantity Wt.NW. <br /> 1. <br /> IV VAJ µ AZ n-f-bMtS <br /> L { <br /> x 2. <br /> W <br /> L7 <br /> 3. <br /> 4. <br /> 13.Special Handling Instructions and Additional Information <br /> 4 Flo FWEC.,r A/0 40,266 <br /> 14.GENERATOR'SJOFFEROR'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 national governmental regulations. <br /> Generalor's60tteror's PrintedfTyped Name Signature SRI Month Day Year <br /> -t c is c v W - z PIPs C tit c-Cd [Z - <br /> J 15.International Shipments <br /> Import to U.S. Export from U.S. Part of entrylexit: <br /> Transporter Signature for exports on : Date ieavin U.S.: <br /> !r <br /> IS.Transporter Acknowledgment of Receipt of Materials <br /> Transporter 1 Printed/T d Name Signatuj I Month Day Year <br /> CA <br /> 4 Transporter 2 Printed+Typed Name Signature Month Day Year <br /> r <br /> 17.Discrepancy <br /> 17a.Discrepancy Indicatton Space <br /> ❑Quantity ❑Type Residue ❑Partial Rejection ❑Full Rejection <br /> Manifest Reference Number: <br /> 17b.Alternate Facility(or General❑o U.S.EPA J Number <br /> J_ <br /> V <br /> L Facility's Phone: <br /> W 17c.Signature of Alternate Facility(or Generator) Month Day Year <br /> [7 <br /> C� <br /> N <br /> W <br /> f] <br /> 18.Designated Facility Owner or Operator.Certilication Areceipt of erials covered by the manliest except as noted I Item 17a <br /> PrintecVTyped Name Signature nth ay r <br /> 169-BLC-05 11977(Rev.9109) DESIGNATED FACILITY TO GENERATOR <br />