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NONHAZARDOUS 1•Generator ID Number 2.Page 1 of 3.Emergency Response Phone 4.Waste T ekfn N bar g� <br /> WASTE MANIFEST 5� Y❑ —❑3(3S d "T40.(11 <br /> 5.Generators Name and Mailing Address Generators Site Address(if drfferent than mailing address) <br /> 7^97L15V&j rj`tU g4!F x,-o V �b 6 3p_ <br /> Y CD-$0Y 7 t Dtrts -T-1 -7Saa qG�-r DA- vWf4 Dv s-roca--foA) cpg� <br /> Gensralor's Phone; <br /> 6.Transparte 1 an�� U.S.EPA ID Num6ej /L <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> S.Designated Facility Name and Site Address p L1.S.EPA ID Number <br /> 1r -TE <br /> �,oZ Pv'C ►� -PtIU6 L&fe SwI kot-j (A <br /> Facili 's Phone: <br /> 9.Waste Shipping Name and Description 14.Containers 11.Total 12.Unil <br /> No, Type Quantity Wt.Nof. <br /> i. <br /> W <br /> x 2. <br /> W <br /> t:3 <br /> 3. <br /> 4. <br /> 13.Special Handling Instructions and Additional Information <br /> L4 Oa 6 0 <br /> 14.GENERATOR'SIOFFEROR'S CERTIFICATION:I hereby declare that the contents of this consignment are fully and a=rately 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 intemationaf and national governmental regulations. <br /> GeneratoesfMeror's Printed)Typed Name signature Month pay Year <br /> rn c c o wr V LL. I <br /> Qtfl' �1 IVIc.C�7►�� r ?� <br /> ..0 15.International Shipments EJ <br /> Import to U.S. ❑Expod from U.S. Port of entrylexit; <br /> Transporter Sinature for expons only): Date leaving U.S.: <br /> fx 16.Transporter Acknowledgment of Receipt of Materials <br /> Transporter 1 Printedrfyped Name Signature Month Day Year <br /> IL 1?144Vze_ <br /> to <br /> c Transporter 2 Printedi ryped Name Signature Month Day Year <br /> F <br /> 17.Discrepancy <br /> 17a.Discrepancy Indication Space <br /> ❑Quantity 1:1 Type 1:1 Residue El Partial Rejection EJ Full Rejection <br /> Manifest Reference Number: <br /> 17b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> U <br /> a Facility's Prone; <br /> 0 17c.Signature of Aftemate Facility(or Generator) Month Day Year <br /> d <br /> L7 <br /> 18.Designated Facility Owner or Operator:Certification of receipt of materials covered by the manifest except as notq in ft 17a <br /> Printedi7yped Name Signature on y Y <br /> 169-BLC-0 5 11977(Rev.9109) V DESIGNATED FACILITY TO GENERATOR <br />