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Oct 17 11 10146a Microsoft <br />.1.,..;.,.,..A F--- — M;fn 140 nunhl h--Af— % <br />916-685-1902 p.18 <br />Form ADDroved. OMB No. 2060-0039 <br />tI-At-0rMtl1VU-ZZ(KUV.J-uD) rFUv1Uu5Uu1Uu11barc uubV1t3LV. W"QV%41— I <br />UNIFORM HAZA RDOUS <br />1. Generator 10 Number <br />Page I of <br />1 3. Emergency Response Phone <br />4. Manifest Tracking NumbeK <br />4 <br />39 JJK- <br />WASTE MANIFEST <br />5. Generaito(&Name and Valling AOdress Generator's Site Address (if different than mailing address) <br />Generator's Phone: <br />6. Transporter 1 Company NameLaitt� U.S. EPA ID Number <br />7. Transporter 2 Company Name l a -T. V�JRY -?Y W.F.ViK)A. k.!-(, U.S. EPA 10 Number <br />8. Designated Facility Name. and Site Address 1 U.S. EPA ID Number <br />Facility's Phone: <br />98, <br />9b. U.S. DOT Description (including Proper Shipping Name, Hazard Class, 10 Number, <br />10, Containers <br />11. Total <br />12, Unit <br />13. Waste Codes <br />No. <br />Type <br />HM <br />and Pecking Group (if any)) <br />Quantity <br />WI.Nol. <br />— <br />0 <br />- ---- <br />rr <br />L <br />J. <br />14. Special Handling Instructions and Additional Information <br />15. GENERATOR'S[OFFEROR'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 labelediplacarded, and are in all respects in proper condition for transport according to applicable international and national governmental regulations. if export shipment and I am the Primary <br />Exporter, I certify [hat the contents of this consignment conform to the terms of the attached EPAAcknowledginent of Consent. <br />I certify that the waste minimization statement identified in 40 CFR 262.27(a) (if I am a large quantity generator) or (b) (if I am a small quantity generator) is true. <br />Gpneralor`;jOflerors POnted[Typed Name SigriptureMonth Day Year <br />-J <br />16. International Shipments <br />Import to U.S. ❑ Export from U.S. I Pert of entry/exit: <br />Transporter signature (for exports only)- t Date leaving U.S.: <br />17. Transporter AcknotAedgmeril of Receipt of Materials <br />Transporter I Printed/Typed Namp sigosture Month Day Year <br />0 <br />W <br />CL <br />en <br />Z <br />Transporter 2 Printedayped Name sig, pire:, Month Day Year <br />18. Discrepancy <br />18a. Discrepancy Indication Space El Quantity Type 0 Residue Partial Rejection ❑Full Rejection <br />F <br />Manifest Reference Number; --- <br />>- <br />18b. Alternate Facility (or Generator) U.S. EPA ID Number <br />Lj- <br />Q <br />Lu <br />Facility's Phone: <br />18c. 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 />U1 <br />1 <br />2. <br />20 Designated Facility Owner or Operator. Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a <br />Printed! typed tJamo t Signature Month Day Yeaf,, <br />tI-At-0rMtl1VU-ZZ(KUV.J-uD) rFUv1Uu5Uu1Uu11barc uubV1t3LV. W"QV%41— I <br />