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Please print or type . (Farm designed for use on elite (12-pitch) typewriter,) Form Approved, OMB No, 2050-0039 <br /> UNIFORM HAZARDOUS 1 . Generator 10 Number 2, Page 1 of 3. Emergency ResponsjPP;ho:ne 4, Manifest Trackin 400475 <br /> Number <br /> WASTE MANIFEST C'` Og02 o p (f 2 (¢ I '?� _ 0 2 0 0 4 7 5 G B F <br /> 4A� IL <br /> "Gener oes Name and Mailing Address Generator's Site Address (if different than mailing address) <br /> 2013 41 SIV" eAr% <br /> gQ�to r3 cow tr(k r t�ticv tZo{ ,. Y <br /> Generator's Phone: w. 2.- ( $rte <br /> 6. Transporter 1 Company Name U.S. EPA ID Number <br /> w �7iti LrC GL� Yr I� �1R O CiA.L. 3co`?� 42 <br /> 7. Transporter 2 Company Name U.S. EPA ID Number <br /> ENVIRONMENTAL <br /> 8. Designated Facility Name and She AddressEP',�, r$TM ENT <br /> � U.S. EPA IO Number <br /> nL t � 5 jt {Zc� <br /> Facii es hn �- 00M C 4C4 <br /> ga 9b. U.S. DOT Description (Including Proper Shipping Name, Hazard Class, ID Number, 10. ConlaEnais 11 . Total 12. Unit 13, Waste Codes <br /> Hhi and Packing Group (if any)) Nov Type Quantity Wt,No1. <br /> Norv- fpcaA w <br /> � Y � � -- <br /> 2. , <br /> 3. <br /> 4. <br /> 14. Special Handling Instructions and Additional Information <br /> C" = Ir? I <br /> 15, GENERATOR'SfOFFEROR'S CERTIF{CATION: t hereby declare that the contents of this consignment are fully and accurately described above by the proper shipping name, arca are classified, packaged, <br /> marked end labeled/placarded, and are In all respects in proper condition for transport according to applicable intemational and national governmental regulations. If export shipment and I am the Primary <br /> Exporter, I certify that the contents of this consignment conform to the terms of the attached EPAAcknowledgment of qpwqnL <br /> I certify that the waste minimization statement Identified in 40 CFR 282.27(a) (if f am a large quantity generator) orpnfla a small quantity generator) Is true. <br /> j Generator's/Offen s Printedfted Name Signature Month Day Year <br /> Awl & <br /> —r 16, international Shipments <br /> ❑ Import to U.S, ❑ Export from U,S. Porl of enWexh: <br /> ( Transporter signature (for exports only): Date leaving U.S.: <br /> s 17, Tr#Upo& Acknowledgment ofReceipt ofMaterials <br /> OTran seortter 1 Printedfryped Name Slgnalu Month Day Year <br /> CL JAJV� (Qr <br /> Q Transporter 2 Printedflyped Name Signature Month Day Year <br /> 18. Oiscrepancy <br /> 16a. Discrepancy Indication Space ❑ Quantity ❑ Type ❑ Residue <br /> ❑ Partial Rejection ❑ Full Rejection <br /> Manifest Reference Number. <br /> 186, Alienate Facility (or Generator) U.S. EPA ID Number <br /> C.! <br /> LL Facllity's Phone: <br /> W 180. Signature of Alternate Facility (or Generator) Month Day Year <br /> 19. Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste treatment, disposal, and recycling systems) <br /> en <br /> UJ L 2. _ . 4. <br /> — - 20r0esjgnaWFaci1Ity Owner or Opprator. Certification of receipt of hazardous materials covered by the manifest except as rioted In Item 18a — <br />° <br /> PrintedPT Name Signature Month Day Year <br /> EPA Form 8700-Z9Rev. 3.05) Previous editions are obsolete. <br /> naarnnrn-r•nn r_ nnn r•+•va•n n � nrr �rx •e•rnar nrn •rw nr. nr ,-. , � , r .- ,•. . <br />