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Please orint or tvoe. (Form designed for use on elite (12 -pitch) Noewriter.l <br />Form Aonroved- OM8 No 2050-0n3q <br />ti -A norm aruu-ze iKev. s-ub) Hrevlous ealuons are ocscleie. GENERATOR'S INITIAL COPY <br />UNIFORM HAZARDOUS <br />1, Generator ID Number <br />2. Page 1 of <br />3. Emergency Response Phone <br />4. Manifest Tracking Number <br />O l 5) 7 2 2 2 6 J J K <br />WASTE MANIFEST <br />- <br />y.r <br />i <br />5. Generators Name and Mailing Address Generator's Site Address (if different than mailing address) <br />fQIr VIV tr�15Y <br />Generators Phone: <br />6. 1 ransporter 1 Company Name U.S. EPA ID Number <br />�_3aTyd �^}.. } tiillF`Y- lrL. .-ip-ti�i �-•.-fish 1 <br />7. Transporter 2 Company Name U.S. EPA ID Number <br />B. Designated Faakry Name and Site Address U.S. EPA ID Number <br />�1V!°R.LL�4irt tilt!. TfarxiyirF�'►? <br />QryJr."MNK. CA ` <br />Fac lid's Phone: ' ;; + ( $1 <br />9a. <br />9b. U S. DOT Description (including Proper Shipping Name, Hazard Class. ID Number. <br />10. Containers <br />11. Total <br />12. Umt <br />13. Waste Codes <br />No. <br />Type <br />HM <br />and Packing Group if a <br />9 P ( mq <br />Cuantit Y <br />Nt,Vcl <br />rY <br />1. <br />V3DFLi4i H/e; ,R uC4c �?�1�i'MG ol'I f Watillri <br />O <br />a— <br />- <br />z <br />2- <br />w <br />0 <br />3. <br />14. Special Handling Instructions and Additional Information <br />ERGO 171 <br />USE GLOV17S <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 labeledlplacarded, 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 Consent. <br />I cenify 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 />GenetaorslOfferors PdnledlTyped Name Signature.. ,yam `Month Day Year <br />q J Q •{ <br />-J <br />16. Intemational Shipments <br />❑ Import to U.S. ❑ Expert`rom U.S. Port of entrylex t: <br />Z <br />Transporter signature (fox exports only): Date leaving U.S.: <br />w <br />17. Transporter AckneWedgment of Receipt of Materials <br />Transporter 1 PrintedlTyped Name' Signature ZDay Year <br />.. . <br />A�l, I <br />/ y�-� ry 'v <br />ZZ <br />Transporter 2 Pnntedrryped Name Signature r` Month Day .� <br />t- <br />18. Discrepancy <br />18a. Discrepancy Indication Space <br />❑ Quantity ❑Type E] Residue ❑Partial Rejection Full Rejection <br />Manifest Reference Number <br />18b. Alternate Facility (or Generator) U.S. EPA ID Number <br />U <br />LL <br />Facility's Phone: <br />LU <br />18c. Signature of Alternate Facility (or Generator) <br />Month Day Year <br />a <br />Z <br />N19. <br />Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste treatment. disposal, and recycling systems) <br />ir•i <br />2. <br />3. <br />4. <br />20. Designated Facility Cwner or Operator. Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a <br />rtediTyped Name Signature Month Day Year <br />ti -A norm aruu-ze iKev. s-ub) Hrevlous ealuons are ocscleie. GENERATOR'S INITIAL COPY <br />