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NON-HAZARDOUS [FGenerator 10 Number 2.Page 1 of 3.Emergency Response Phone 4.Wa Tcki umber ^^ <br /> WASTE MANIFEST S —r)a . <br /> 5.Generator's Name and Mailing Address Generator-Site Address(if different than mailing address) <br /> 0. 3 I'a <br /> aj -1 t t I -�-5 71 -15)a 1 ,r/)-7 � V�►��r �� S-T 0 c�-r OfJ <br /> eneratar's Phone: <br /> 6.Transporter 1 Company Name U.S.EPA ID Num or <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> s.Designated Facility Name and Site Address U.S.EPA ID Number <br /> fl��� <br /> 367� Vd•7 M pu g 4� l r�1 (4.vqq s <br /> Facili 's Phone: <br /> 9.Waste Shipping Name and Description 10.Containers 11.Total 12.Unit <br /> No. Type Quantity WtJvol, <br /> 1. <br /> LU <br /> z 2. <br /> LAJ <br /> 3. <br /> 4, <br /> 13.Special Handling Instructions and Additional Information <br /> L 6L) <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 labeled/placarded,and are in all respects in proper condition for transport according to applicable international and national governmental regulations. <br /> GernerstorsfOfferorts Printed/Typed Name Signature Month Day Year <br /> V pr—1 V4 cu M L CSN Al iL FRI'v1 cC r\A C Coki Nth I n <br /> a I fk International Shipments <br /> Import to U.5. Export from U.S. Port of entry/exit: <br /> Transporter Signature for exports only): Date leaving U.S.: <br /> cc IS.Transporter Acknowledgment of Receipt of Materials <br /> Transporter 1 PrintedlTyped Name Signalure Month Day Year <br /> N+ �1 11 1'zp <br /> a Transporter 2 PrintedlTyped Name Signature Month Day Year <br /> 17.Discrepancy <br /> 17a.Discrepancy Indication Space ❑ ❑Type ype ❑Residue ❑Partial Rejection ❑Full Rejection <br /> Manifest Reference Number; <br /> 17b.Alitemate Facility(or Generator) U.S.EPA ID Number <br /> C7 <br /> Facility's Phone: <br /> 17c.Signature of Alternate Facility(or Generator) Month Day Year <br /> C7 <br /> V! <br /> I&Dwignafed Facility Owner or Operator:Ce �n of receipt of materials covered by the manffest except as noted In 7 7a <br /> PrintedlTyped Name Signature Wh D at <br /> 169-BLC-O 5 11977(Rev.9109) DESIGNATED FACILITY TO GENERATOR <br />