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Pie e pr I o; type. (Form designed for use on elite 12-pitch) typewriter.) GENERATOR R N1N-HAZARDOUS <br />kSTE MANIFEST <br />ID Number <br /> <br />1g Generator.Add <br />tc) //4 <br /> <br />orator's Name and Mailin <br />ess <br />Genewiet s site Address lit ()dewi then mlt1 rg adgr,iss) <br />2. Page 1 of <br />/ <br />3. Emergency Response Phone tvi.1 <br />e00 -P6fq - t1G7?-- *11-)74 <br />4. VVaste Trucking Number <br />8?0 - CC- - o 7-. le- 2. a l <br />‘5.. G. <br />CA <br />18"° <br />Generator's <br />pievs-roo <br />ora-rui roe : 1.4 Art.MA OW Mir 01,0 (au ei 42 <br />e rA 'iv I-in n,IJ pazjw..) sloe, o .fimge,A) SHIP I Me *. clO•Sti 9 14 <br />Logsr t-eo v s.ort4 , 5--.1r0 14I3; e aci-r ° Moog-610 r3E12-T14 * i <br />TN.-}90 29. I SroC(C/T),...y5A otr 23, T <br />Phone .' 34C- 388 - 07 414 <br />6. Transporter 1 Company Name U.S. EPA ID Number <br />AITZ C /-:-.3tiVifloA, in.-A2r.9.-1.- S22v/cEr /A/C, 109R Moo Jo //v <br />7 Transporter 2 Company Name U.S EPA ID Number <br />I <br />8 Designated Facility Name and Site Address US. EPA ID Number <br />R, rii 072 6 /1/41 4 S. t4A/of/zz <br />,7C7-s" is'orizogo IPLL S. LA) <br />,r(14,11.41 e / ry, el.? f i/ .1-85 <br />Facility's Phone: ? 0 P — ?J2 - W 21 j 69/2 oocog 7 9‘.6 <br />ga. 9b. U.S DOT Description (including Proper Shipping Name, Hazard Class, ID Number, 10. Containers 11 Total 12. Unit <br />HM and Packing Group (if any)) No Type Quantity Mot <br />1. AMA/- go? Z ArLD our Lvi9-57-45.7, ra e lo, vb-Gfrm oz_6- oil_ !Art prk ScrarteWri- opk.fro Afrazt- <br />(76445- <br />Cril <br />17- 11- S-c. <br />Special Handling Instructions and Additional Information <br />e".1 <br />Fe-tpli-a* ?H- 2-z, -348 <br />GENERATOR'S CERTIFICATION: I certify the materials described above on th's manifest are not subject to federal regulations for reporting proper disposal of Hazardous Waste. <br />GenemtorslOtleroes Printed/Typed Name ....-----, 1 Signature Month Day Year <br />I ‘-/ I. e—c--- (:7cr,--5 3 1 I e 1 <br />-I 15 International Shipments Import to U.S. Export from US. Port of entry/exit: <br />-,- Transporter signature (for exports only): Date leaving U.S.: TRANSPORTER] 16 Transporter Acknowledgment of Receipt of Materials <br />Transporter 1 PnntediTyped Name Signature Month Day Year <br />..-/---- jO se Ct-tuz."Alo ___,.......-----7---. 1`;'3 1 18 i za- <br />Transporter 2 Printed/Typed Name Month Day Year <br />I I I DESIGNATED FACILITY Discrepancy <br />17a. Discrepancy Indication Space Quantity EliType El Residue Partial Rejection Full Rejection <br />Manifest Reference Number <br />17b Alternate Facility (or Generator) U.S.EPA ID Number <br />Facility's Phone: I <br />17c. Signature of Alternate Facility (or Generator) Month Day Year <br />I I <br />\ <br />I materials covered by the maNfest except as noted in Item‘ 1 .41k <br />t <br />Designated Facility Owner or Operator. Certikatio 1 receip <br />Printed/Typed Name Signature ,Ionliiii:Ily ( tar <br />I z 1 I <br />6 Nii It.i-C, 11 <br />1-DE TED FACILITY TO atTiNATION