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rte print or type. (Form designed for t <br />UNIFORM HAZARDOUS 1. Ge"e1 <br />WASTE MANIFEST <br />i. Generalors Name and Mining Address <br />Y <br />:PLC?F.4'p:a: h53r:Et <br />Cry ?537F <br />Generator's Sle Address (ddiflerenl than reading ac <br />4' irly (i Certhzil' <br />7. Tgnsparler 2 Company Name` <br />U.S. EPA ID Numbe! <br />OMB <br />8. Designated Fabliy, Name and Site Address U.S. EPA ID Number <br />Cl -FERN MRSORS El�U:Ft�TJ`,i:? T -:L S-' =St y <br />i.'.i Z i... {V <br />F; 1�7'1'11wpy 71 <br />1. <br />K I MALL h4: CrS P 5 <br />FauU 's Phone: .. - -" ' . `.S09S 1. rCt-:JJ <br />ga <br />96. U.S. DOT Desmpbcn (iiduding Proper Shippig Name, Hazard Clara C Number <br />10. Conlaners <br />11. Total <br />12. UnT <br />HIM <br />and Packing Group (if any)) <br />Quantity <br />WUvpt <br />13. Wl Cabe <br />Na. <br />Typo <br />1 <br />p <br />r <br />aYA^ i :I t Jx111ti' WAS TETRU M)d <br />7Lift=s <br />1:E <br />t':': 7 ii%il-A <br />• • <br />a <br />".� r,J_.Et4Dt i1;•S7; <br />z <br />2. <br />i <br />3. <br />I <br />14. Spedal Handing Ins¢uc6ons and Addibcoal Information <br />766 17001 <br />i 7, <br />•_:1 1.�;? T'•!:f�r^.)F_ `v x;<—�,�!G.�ntici_r?c,(a; •�': ry 7 It% <br />15.-GENERATOR'SIOFFEROR'S CERTIFICATION: I hereby dedaie that the contents of Nis consgnmen! are f,{ y aid as rately desmbed above by the proper shgping name, and are classified, packaged, <br />marked and Iabeiecklacarded, arid area all respects in proper condition for transport according to appincable Intem unit and national 90v 111emal regus6ons. If export shipment and I am the Primary <br />Exporter, I cerGly cut the contents of this pnsiignmenl wMann to the terms of the attached EPAAcknoMedgment of Consent. <br />I cerify th at the wase MMUMIvabn slaerhant iden0fied in 40 CFR 262.27(a) (d I am a large quantity generator) or (b) If I am a small quantity generator) is Ims, <br />Genefatus/Offero's vents Typed Name Sgnature - Month Day Neer <br />tiwnal Shipmentsr <br />WU.S. ❑Export hom U.S.Pod <br />SgnaWre ilw experts only❑� <br />of Dale ofentry/ext avig U.S.: <br />oMrAcknoMedgmen of Rece;pl of MeledWsr <br />VVJ:n�rrrwiter <br />1 Prnted7Typed Name_ Sgna!ure <br />Month Day <br />J1((f"�f <br />..r4t <br />Jr <br />2 Pnnted/fyped NameSgnalare MmM p�. Ner <br />} <br />18. Discrepancy <br />18a, Discrepancy Indation Spat El Quantity ❑Type []Residue ❑ Pallial ❑Full <br />Rejection Rejection <br />Mzngesl Reference NunZer. <br />18b, Aeemxle Fadity (w Genersm) <br />J <br />U.S. EPA IO Number <br />U <br />tai <br />FacdiVs Phone: <br />w <br />1&. Signature of Alternate Facgity(or Genembor) <br />Akn;.n Day Year <br />z <br />y19. <br />Hazardous Waste Repan Management Method Codes (i.e.. codes lar hazardous vresle treatment d511osai, and recycling systems) <br />r, 1 <br />2. <br />3, <br />4. <br />20.Des;gnated <br />FaSiity Ovmera0 ratocC gicalmofmceiptofhazardarsmalenalscoveredby Rremani•estexcep'aseaedinlleml8a <br />Pnnled4ypetl <br />Nemo Sigerviro Mcith Day Yea, <br />PDA e.....,aInMmtie_, <br />anu r%-..:___ ---- ____.__I . <br />