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4OF T <br /> 'AAZARDOl1S 1,Generator ID Number 12.Page 1 of 3.Emergency Response Phone 4.Waste Tracking Number <br /> WASTE MANIFEST -„- S�, <br /> 5.Generator's Name and Mailing Address Generator's Site Address{if different than mailing address) <br /> ?E-ie tr <br /> PJ L7 <br /> v.. <br /> Generator's Phone' <br /> 6.Transporter 1 Company Name U.S.EPA ID Number <br /> RES Eta,+iformTelltai Serelus <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> 6.Designated ar 1Ntfdame and Site Address U.S.EPA€D Number <br /> 11.05 Airpofl Rd G <br /> Fk�pE5t8.t h, <br /> Facili 's Phone: F3t7 rn'15 � <br /> g.Waste Shipping Name and Description 10.Containers 11.Total 12.Unit <br /> No. Type Quantity Wt.Nol. <br /> cc i 1air7tb ou-s wazitE fiquiti {grourta,w3jeo 1 T <br /> 01 T <br /> cc <br /> ix _ <br /> w <br /> z <br /> w 2 <br /> 3. <br /> c <br /> 4. <br /> 13.Special Handling Instructions and Additional Information <br /> i <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/piacarfed,and are in all respects in proper condition for transport according to applicable international and national governmental regulations. <br /> Generators/Offerors PrintedlTyped Name Signature Month Day Year <br /> 26 <br /> 16.international Shipments <br /> P- ❑Import to U.S. El Export from U.S. Port of entry/exit: <br /> Transporter Signature far exports only): Date leaving U.S.: <br /> cc w 16.Transporter Acknowledgment of Receipt of Materials <br /> cc Tr pprter 1 Printed/Typed Name Signature f Month Day Year <br /> m ..� <br /> z Transporter 2 Printed/Typed a Signature Month Day Year <br /> 17.Discrepancy <br /> 17a.Discrepancy fndicalian Space <br /> Quantity Type ❑Residue ❑Pallial Rejection ❑Full Rejection <br /> 21,2160 Manifest Reference Number: <br /> 17b.Alternate Facility(or Generator) U.S.EPA IU Number <br /> J <br /> U <br /> Facility's Phone: <br /> w 17c.Signature of Alternate Facility(or Generator) Month Day Year <br /> z <br /> c� <br /> w _ <br /> t] <br /> 16.Designated Facility owner or Operator:Certification of receipt of materials covered by the manifest except as noted in Item 17a <br /> PrintedlTyped Name Signature Month Day Year <br /> 4 <br /> 169-ELC-0 5 11977(Rev.91091) DESIGNATED FACILITY'S COPY <br />