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Please Drint or Wine. (Form designed for use on elite 112-nit0il tvnawrilar 1 <br />Corm Ann -A nhAR hl. lnan nnn <br />LHA I-orm vuui-zit (ttev. ruoi rrevious eamons are ocisoiete. DESIGNATED FACILITY TO GENERATOR <br />UNIFORM HAZARDOUS <br />1. Generator ID Number <br />2. Page 1 of <br />3. Emergency Response Phone <br />4. Manifest Tracking Number <br />WASTE MANIFEST <br />�:,•S1,' �7i1.;t1f'i:i <br />:(} <br />2 6 JJ K <br />.'1:-722` <br />5. Generators Name and Mailing Address Generators Site Address (if different than mailing address) <br />lilF;'014i i;t:,frF.N <br />�r1•t �.:aTri:.Jr � �.t(�t <br />Generators Phone: <br />6. Transporter 1 Cotnpany Name U.S. EPA ID Number <br />4j•;7:- <br />7.. Trarsporfer2 Company Name U.S. EPA ID Number <br />8. Designated Facility Name and Site Address U.S. EPA ID Number <br />FIrlr'fk':J/U,JK, <br />Facilitys Phone: I.-;;-b1-;:•-BIC.1 <br />ga. <br />9b. U.S. DOT Description (including Proper Shipping Name, Hazard Gass, 10 Number, <br />10. Containers <br />11. Total <br />12. Unit <br />13. Waste Codes <br />No. <br />Type <br />HM <br />and Packing Group (if any)) <br />Quantity <br />Wt.N01: <br />� <br />.'i 111;'it{f,� <br />J.1 <br />z <br />2. <br />I <br />LU <br />1 <br />1 <br />3. <br />i <br />4. <br />I <br />14. Special Handling Instructions and Additional Information <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 I@beled(placarded, and are in all respects in proper condition for transport according to applicable intemafional 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 fine attached EPAAcknowledgment of Consent. <br />I certify that the waste minimization stalement identified in 40 CFR 262.27(a) (if I am a large quantity generator) or (b) (tf I am a small quantity generator) is true. <br />GenfrpkrslOfierorsPrintedfiypedNam Sig Month `Day Year <br />lo <br />j <br />1- <br />16, International Shipments <br />❑ Import to U.S. ❑ Expod from U.S. Port of entryle)it <br />z <br />Transporter signature (for exports only): Date leaving U.S.: <br />W <br />17. Transporter Acknowledgment of.R_ ereipt of Materials <br />Transporter lPrinteQTypedNa a ,� <br />Signature Mont Day Year <br />0CL <br />F <br />2 <br />x 'Sgnalure <br />aTransporter <br />2 Printed( Iyt a `- 1 Month Dap XW <br />G.' <br />1-- <br />1B. Discrepancy <br />f8a. Discrepancy Indication Space quantity ❑ Type ❑ Residue ❑ Partial Rejection ❑ Full Rejection <br />Manifest Reference Number: <br />18b.Altemate Facility (or Generator) U.S. EPA ID Number <br />U <br />tai <br />Facility's Phone. <br />w <br />18c. Signature of Alternate Facility (or Generator) <br />Month Day Year <br />Q <br />z <br />Fn <br />19. Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste treatment, disposal, and recycling systems) <br />LLIC3 <br />2. <br />3. <br />4. <br />20. Designatilld Facility Owner or Operator: Certification of rg eipt of hazardous materials covered by the manifest except as noted In Item 1 Ba <br />Printedlryped Name / Signature �.o Month Day Year <br />, ,� t t <br />i //f fV �' ��."'i A7 <br />LHA I-orm vuui-zit (ttev. ruoi rrevious eamons are ocisoiete. DESIGNATED FACILITY TO GENERATOR <br />