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NON-HAZAFIOOUS 1.Generator ID Num her 2.Page 1 of 3.Emergency Response Phone 4.Wa Tracking INVMber <br /> WASTE MANIFEST �5 �s�7Li <br /> 5.Generator'ss Name and Mailing Address Generators Site Address(i1 different than mai Iij address] <br /> [—eLevu,j 7--ELe4a! 5TOttF— *F '7-06';2- <br /> F.C. <br /> 7-0i'7 <br /> 1- <br /> FiV W CA `fin GKo� �q 5so <br /> e s ? ' <br /> 6.Transp pr 1 Com any e� /] U.S.EPA ID Number <br /> 7.Tran'sFaTert Company Name y U.S.EPA ID Number <br /> 8.Designated Facility Name and Site AddressLL U.S.EPA ID Number <br /> ww�-re co NY fjecrw 1,j <br /> 305' vanvRq-a Ltkm- L4 54I%w c- zi4f$5r Af��' <br /> Faci1' s Phone: <br /> 9.Waste Shipping Name and Description 10.Contalners 11.Total 12.Unit <br /> No. Type Quantity Wt.Nol. <br /> NW- k� t&5 �� t 501� (Sol L-} <br /> LU <br /> z 2. <br /> l �f. 1 <br /> LU <br /> 3. <br /> 4, <br /> 13.Special Handling Instnictions and Additional Information <br /> jf l L 11— t o v 84, 4 L1c AA) - P�LF -- 74.:2— $9� <br /> SGT N4 : n26 v <br /> 14.GENERATOR'SIOFFEROR'S CERTIFICATION:I hereby declare that the contents of this oonsignmerrt are fully and accurately described above by the proper shipping name.and are classified,packaged, <br /> marked and tabeledrplacarded,and are in all respects in proper condition for transport according to applicable intomational and national gmmmental regulations. <br /> Generator'slOffmr's Printed/Typed Name Signalure Month Day Year <br /> -.+ 15.International Shipments <br /> ❑impart to U.S. Ll Export from U.S. Part of entrylexit: <br /> Transporter Signature for exports only): Date leaving U.S.: <br /> rr 16.Transporter Acknowledgment of Receipt of Materials <br /> LLF <br /> Transporter nted(Typ Name Signature Month Day Year <br /> Vo <br /> a Transports rinfk7yped Name Signature Month Day Year <br /> x <br /> 17.Discrepancy <br /> 17a.Discrepancy Indication Space ❑Quantity ❑Type ❑Residua ❑Partial Rejection ❑Full Re0d. <br /> Manifest Reference Number. <br /> r 17b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> to <br /> U <br /> L Facility's Phone: <br /> W 17c Signature of Alternate Facility(or Generator) Month Day Year <br /> a <br /> x <br /> wW <br /> O <br /> 1 S.Designated Facility Owner or Operator:Cerhficatlon receipt o rials covered by the manifest except as no in Item <br /> Printed/Typed Name Signaturejf`M0jh Y r <br /> 169-BLC-0 5 11977(Rev.9149) DESIGNATED FACILIT TGG ERATOR <br />