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II I <br /> }I4 111,AADDUS 1 Generator tD Number 2.Page 1 of 3.Emergency Response phone 4.Waste Tracking Number <br /> ,WAStE MANIFEST <br /> ,Generator's Name and Mailing Address Generator's Site Address(if different than mailing address) <br /> + N�so,i3 71; ?is,i-.�; an`a,*,._..= <br /> Generator's Phone: <br /> 6.Transporter 1 Company Name U-S_EPA ID Number <br /> 7.Transporter 2 Company Name U.S.FPA ID Number <br /> B.Designated Fadi Na e and Srte Address U.S.EPA ID Number <br /> Rn <br /> IIf Lt <br /> RIS .z ... <br /> Facili 's Phone: <br /> 9.Waste Shipping Name and Description 10.Containers 11.Total 12.Unit <br /> No. Type Quantity VVII.Nol, <br /> !Z <br /> 4 <br /> a <br /> a: <br /> Lu <br /> z 2. <br /> w <br /> 3. <br /> 4, <br /> 13.Special Handling Instructions and Additional Information <br /> 14.GENERATOR'S/OFFEROR'S CERTIFICATION:I hereby declare that the contents of this consignment are fullynd accurately described above by the proper shipping name,and are classified,packaged, <br /> marked and labeledlplacarded,and are in all respects in proper condition for transport according to applicable i ter ational and national governmental regulations. <br /> GeTtor's/Offeror's Printec!VTypad Name Signature Month Day Year <br /> J 15.International Shipments <br /> ❑Import to U.S. ❑Export from U.S. Port of entry/exit: <br /> Transporter Signature for exports only): Date leavin U.S.: <br /> W 16.Transporter Acknowledgment of Receipt of Materials <br /> w Transporter 1 Printedffyped Name Signature Month Day Year <br /> f <br /> Transporter 2 PrintedfT ed Name Signature a Month Day Year <br /> 17.Discrepancy <br /> 17a.Discrepancy Indication Space <br /> ❑Quantity ❑Type ❑Residue ❑Partial Rejection <br /> I ❑Full Rejection <br /> i <br /> 17b.Alternate Facility{or Generator) Manifest Reference Number: U.S.EPA Ib Number <br /> J <br /> U <br /> rat Facility's Phone: <br /> LLJ 17C.Signature o1 Ahernate Facility(or Generator) <br /> Month Day Year <br /> Z <br /> W <br /> W <br /> a <br /> 18.Designated Facility Owner or Operator:Certification of receipt of materials covered by the manifest except as noted in Item 17a � <br /> PrinledTypedName /f , Signature fJ Month Day Year <br /> �r dJ 1 /7 <br /> 169 BLC-O 6 11977(Rev.9109) DESIGNATED FACILITY'S COPY <br />