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NON-HAZARD0US 1•Generator lD Number 2.Page 1 of 3.Emergency Response one 4.W race ng Number <br /> WASTE,MANIFEST 1 ❑5 ❑— 0 3 DS <br /> •5,G veraa���d Mai lilig Address Generator's Site Address of di Brent han i[mg address) <br /> (J -SIC c K?21 <br /> Gerkralor s Phone + 1 I V' iI V <br /> 6,Trans e 1 e U.S.EPA ID Number <br /> ) J-- — �jm — <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> &Designated Facility Name and Site Address U-S.EPA ID Number <br /> "e-TC c�N+���-rco►.�5—�� H�u.s NMu. r <br /> (a`l� POTT.el�o "ups 1,we t 5015u."1 t (A 01445-35' <br /> Facility's Phone: <br /> S.Waste Shipping Name and Description 10.Containers 11.Total 12.Unit <br /> No. Type Quantity Wt.Nol, <br /> w <br /> z 2. <br /> w <br /> CS <br /> 3. <br /> 4. <br /> 13,Special Handling Instructions.and Additional Information <br /> 14.GENERATOR'SfOFFEROR'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 Iabeledlplacarded,and are in all respects in proper condition for Iransport according to applicable international and national governmental regulations. <br /> Ganeralof ufferor's Prinledlfyped Name Signature Month Day Year <br /> no< &&c(0N1qA_ 13 1 <br /> J 15.IntemdUcinal Shipments ❑Import to U.S. ❑Export from U.S. Port o1 entryle4: <br /> 19 Transporter Signature for ex arts Only): Date lean U.S.; <br /> it 16.Transporter Acknowledgment of Receipt of Materials <br /> W <br /> Tran arter 1 PAN Typed Name � Signal ura Month Day Year <br /> IV <br /> a Transp r not ed Name Sgnatu Momh Day Year <br /> 17.Discrepancy <br /> 17a.Discrepancy Indication Space ❑ ❑Ty" L1 Residue 1:1 Partial Rejection ❑Full Rejection <br /> Manifest Reference Number: <br /> 17b.Alternate Facility(or Generator) U,S-EPA ID Number <br /> J_ <br /> ri Facility's Phone: <br /> � 17c.Signature of Altemate Facility(or Generator) Month Day Year <br /> lJ <br /> LUW <br /> 1&Designated Facility Owner or Operator:Certification of race materfals covered by the manifest except as noted in Item 17a <br /> PdntedrTyped Name Signature Y <br /> 169-SLC-0 5 11977(Flev.9109) 1<J L11DESIGNATED FACILITY TO GENERATOR <br />