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Please print or type.(Fom1 designed for use on elite(1 itch)tyFv rites) Form Approved.OMB No.2050-0039 <br /> UNIFORfd HAZARDOUS I.Generator IDNumber <br /> 12.Pagelof 3.Emergency Response Phone Manifest TrackingNumber <br /> WASTE MANIFEST /'n u(1 j3 '0 �'j ; ,lX.14. <br /> 003579278 JJ K <br /> Generator's Name and Mating Address / Generator's Site Address(d different than mailing address) <br /> r JA1E q (lei <br /> z7vu�11��//, Vitsl7irJ��r+, <br /> 8.Trraansporrler IC pany Nae U.S.EPA ID Number <br /> e 77a r/S: <br /> ' /) 'l ; 5/ 3632 <br /> 7 Transporter 2 Company Name U.S.EPA ID Number <br /> 8 Dorsi nated Fac,ity Name and Site Address U.S.EPA ID Number <br /> r. <br /> UQ�/(� .S,<i-�i) J)751. J /� p )/n <br /> Fa�1i y's P�ione. 1/n�f{ /-�f/-.!fi � / <br /> ga 9b.U.S.DOT Description(includ rig Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12,Un,t <br /> Hf.l and Packing Group(if any)) No. Type Quantity Wt Not. 13.Waste Codes <br /> Z 2. <br /> w <br /> 0 <br /> 3. <br /> 4 <br /> i <br /> Special Handling Instructions and Additional Informalpn <br /> ;l,�i f�9,•'��lrt' . /t/c%��/�;'J , „J/ -ne <br /> Oils Y7 . B <br /> 15. 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 labeledlplacmded,and are in all respects in proper condition for transport according to app!icab!e international and national governmental regulations.If export shipment and I am the Primary <br /> Exporter,I semi that the contents of th!s consignment conform to the terms of the attached EPAAcknoe.ledgment of Consent. <br /> certify that Bre 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 We. <br /> Gene_r7aloeslOtieror's PrintediTyped Name Signature ' Month Day Year <br /> 16.nteinational Shipme <br /> F <br /> 1:1 Import to U.S. ❑Export from U.S Port of (exit: <br /> Z Transporter signature r exports only): Date leaving U.S.: <br /> 17.Transporter Ackwhiedgment of Receipt of Materials <br /> Transporter intedlTyped Na Signature Month Day Year <br /> CO) <br /> TKnsp-oWeR2 Phntidfryped Name Signaluee Month Day Year <br /> 18 Discrepancy <br /> 18a.Discrepancy Indication Space [] Quantity Type ❑Residue ❑Partial ejection ❑Fu'I Rejection <br /> ' 113 [Oj" SliUrtl� A-AU f�ff?Ar"A�t4� !.t/.QSiE !)c4trrU5)�y0� , ,9/i9 r%)',. ,'1, <br /> Manifest Reference Number. <br /> 18b.Alternate Fac?,ity(or Generator) U.S.EPA ID Number <br /> J <br /> U <br /> LL Fau4ty's Phone. <br /> w I8c.Signature of Alternate Facility(or Generator) Month Day Year <br /> ZZ <br /> C:A a Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> 2. 3. 4. <br /> � !yl <br /> 20.Des!gnated Facility O:.ner or Operator:Certification of receipt of hazardous materials covered by the manifest ex§ept as noted in Item 18a <br /> Pn�ed/Typed N me Signature f bnth Day Year <br /> M 1 (► {, U <br /> EPA Form 0- (Rev.3-0 Previous editions are obsolete. DIESIGiVATEOFACILITY 10 GENERATOR <br />