Laserfiche WebLink
NONHAZARDOUS i.Generator ID Number 2.Page 1 of 3.Emergency Response Phone 4.W ra Track[ umber F_ O� <br /> WASTE MANIFEST N Vas p - 0-S 4 QUO5. efator Oma d M ling Address tor's Site dress(if iffere t than mailing address) <br /> Phone: 9�I <br /> Generators �Ii �� 1 �z� -zJ <br /> 6.Transporter I Company Name U.S.EPA 10 Num r <br /> 7.Transporter 2 Company Name U.S.EPA fl)Number <br /> 8.De igna�ed�a ty lJ�{ne an Si e�c,�•� ��'1 U.S.EPA ID Number <br /> Foci oJP��'Sl,� .AM <br /> 9.Waste Shipping Name and Description 10.Containers 11.Total 12.unit <br /> No. Type Quantity Wt.Nol. <br /> 4 <br /> A)04 � � k1oj-'_g S I k <br /> w <br /> 2 2 <br /> W <br /> i7 <br /> 3. <br /> 4, <br /> 13.Special Hling Instructions and Additlonai Information <br /> S6, rq61- 1d'P% �wk <br /> a-l v� PhfO Aa. �Olbrd <br /> 14.GENERATOR'SIOFFEROR'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 labaledlpla arded,and are in all respects in proper condition for transport according to applica temational anational governments[regulations. <br /> Ge 91P, Ir v Si , Month Day Year <br /> H 15.In[ t anal Shipments ❑Import to U.S. ❑Export Irom U.S. Port of entry/exil: <br /> Transporter Si natu lfor exports only): Date leaving U.S.: <br /> ¢ 16.Transporter Acknowledgment of Receipt of Materials <br /> W <br /> Transporter 1 Prinfed[Typed Name Signature Month Day Year <br /> a <br /> 4 Transporter 2 PrinledfTyped Name Signature MonA Day Year <br /> 17.Discrepancy <br /> 17a.Discrepancy Indication Space T ❑Partial Re' on ❑Full <br /> 11 Quantity ❑ ype Residue tech Rejection <br /> Manifest Reference Number: <br /> 17b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> J <br /> U <br /> LL Facility's Phone: <br /> Lu 17c.Signature of Alternate Facility(or Generator) Month Day Year <br /> ti <br /> z' <br /> C7 <br /> ww <br /> 0 <br /> 18.Designated Facility Owner or Operator: ertifrcafi receipt of malerials covered by the manifest except as noted in Item <br /> PrintedlTyped Name Signature anth y r <br /> 16"LC-05 11977(Rev.9109) DESIGNATED FACILIT f TO GENERATOR <br />