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NQN•HAIARIDOUS 1 1•Generator ID Number2.Page 1 of 3.Emergency Response Phone 4.W Tracking Number <br /> WASTE MANIFEST j SO 5 Q❑- E]$ Ac 4 <br /> 5.Generator's ame and Mail-n Address Generators Site Address(if different than mailing address) <br /> General r s PhDnA <br /> 8.T o 1 CM U.S.EPA ID Number <br /> i <br /> 7.Transporter 2 Company Name US.EPA ID Number <br /> 8.Or <br /> Facili erne rd�5ite Ass_ ,. . /1 U.S,EPA ID Number <br /> Facil s Ph :P19 /' r v r1[/ <br /> 1 <br /> A.Waste Shipping Name and Description No, <br /> S 1.Total Unit <br /> No., W Type Quantity I.NoI, <br /> Joj 6g gl��Jsdlg LS, 1 ) <br /> 2- <br /> 4. <br /> 13pecial Sndling instructions and ditmnal Information ``ll <br /> 01 T �� 110 (} P4 F1 j4 k)0. Y � � Zo, q <br /> !�� a-1 d o <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 labeledlpl carded,and are in all respects in proper coration for transport according to al international and Zonal governmental regulations. <br /> G rs! or<sP )ped e� n� 51 �;�' Mo Day Y ar <br /> J 15.Inte banal Shipments t/j', !V', <br /> Import to U.S. Export from U.S. Port of entry/ext: <br /> Transporter Signature ifof exports only): Date leaving U.S.: <br /> cc 16.Transporter Acknowledgment of Receipt of Materials <br /> W <br /> F Transporter1 PrintedlTyped Name Signature, Mon Qty ear <br /> OC LJ `J/ <br /> -CTO-r/140 i7Q S �►•ry 14 <br /> N <br /> Transporter 2 PrintecUTyped Name %rialure Month Day r <br /> 17.Discrepancy <br /> 17a.Discrepancy Indication Space ❑Quanlity ❑Type ❑Residue ❑Partial Rejection ❑Full Re1ee611 <br /> Manifest Reference Number: <br /> 17b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> J_ <br /> f1 <br /> .4 Facility's Phone: <br /> uj 17c.Signature of Alternate Factiby(or Generator) Month Day Year <br /> a <br /> x <br /> cs <br /> in <br /> w <br /> 0 <br /> 18.Designated Facility Owner or Operator:Certil 'on of a aterials covered by the manifest except as Hated in Item 17a <br /> Printedrfyped Name Signature Month D r <br /> 169-Bl 5 11977(Rev.9103) DESIGNATED FACILI Y TQ 6N&ATOR <br />