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NON-HAZARDOUS f•Generator 1D Number 2.Page 1 of 3.Emergency Response Phone 4.Waste Tracking mbar <br /> WASTE MANIFEST P' S0 O v �AV <br /> leneratortName an��g Address Ge�rafor's 5'rf�� 'f d' re Nra��i�address <br /> er,�at�Phoma I rTY 921 �z ��►� , � <br /> 6.Transport r Name U.S.EPA ID Number <br /> 7.Transportert C6mpa4 Name U.S.EPA ID Number <br /> 8,� a Facility Name and Is dre� � ,/� U.S.EPA IQ Number <br /> 116 71! ��T `IIT �'�i r�� �J <br /> Facile 's Phone. <br /> 9.Waste Shipping Name and De nption 14•Containers 11,Total 12.Unit <br /> No. Type Quantity WtRal. <br /> iE <br /> 1 ►� T�i �sb fI <br /> M al 1 <br /> 2. <br /> 3. <br /> 4. <br /> 13.Special HandlingInstructions and ditional Information <br /> SGS' 1 sc,_���'A <br /> Wvs_ 01 LI <br /> 14.GENERATOR'S/OFFEROR'S CERTIFICAMN: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/placard ,and are in ail respects in proper condition for transport according to applicable international and r1ational governmental regulations. <br /> Genera He rifI[e¢Q d Name Signa t _r Mgg111 y Ye6C <br /> ..1 15.Intemab nal Shipments Import <br /> ❑Import to U.S. ❑Export from U.S. Port of entry/axil: ',1V! I/i�J` +►Q3/1 <br /> Transporter Signature for exports only): Dale leaving U.S.: <br /> m 16.transporter Acknowledgment of Receipt of Materials <br /> Transporter 1 PrimedRypaName Signature Y r <br /> C6 A) <br /> uz <br /> Transporter 2 i5rintedfryped Name Signature Month Day Year <br /> i` <br /> 17.Discrepancy <br /> 17a.Discrepancy Indication Space ❑Quantity ❑Type ❑Residue ❑Partial Rejection ❑Full Rejection <br /> Manifest Reference Number: <br /> r 17b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> ..r <br /> U <br /> .14 Facility's Phone: <br /> 17c.Signature of Alternate Facility(or Generator) Month Day Year <br /> Q <br /> Cf <br /> N <br /> W <br /> f] <br /> 16.Designated Facility Owner or Operator:Certification of receipt of mate ricovered manifest except as noted in Ilem a <br /> Primedfryped Name Signaturenth Y <br /> 169-BLC-0 5 11977(Rev.slo5) DESIGNATED FACItIT TQ GENERATOR <br />