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Please print or type. (Form designed for use on elite (12-oitA&ter 1 <br />g-203 <br />"'""" """'""' "` ""'"" DESIGNATED FACILITY TO DESTINATION STATE (IF REQUIRED) <br />- - Fond Approved. VMC N0, 205M039 <br />UNIFORM HAZARDOUS 1. Generator ID Number 2. Page 1 of 3. Emergency Response Phone nifest Tracking Number <br />WASTE MANIFEST 002 <br />0 2 O /) 2 A <br />'t .7 J J f C <br />5. Generators Name and Mailing Address Genera o s e Address (if different than mailing address)` <br />lied Aerospace Structure <br />APPlied Aerospace Structure <br />.G. Box 6169 3437 So. Airport Way <br />akmaebar* A09-983-3339 Stocit irlCA95206 <br />J. Transporter i Gam <br />U.S. EPA ID Number <br />"MER L EfJVIk0 JMSnKAL t!A O'T SIJc. CAD9S364 So <br />7. Transporter Company Name U.S. EPA ID Number <br />8. Designated Facility Name and Site Address U.S. EPA ID Number <br />edia ES Technical Solutions, L.L.C. <br />- <br />1125 Hensley Street0044 <br />FW, <br />ga, <br />9b. U.S. DOT Description (including Proper Shipping Name, Hexed Class, ID Number, <br />10. Containers <br />11. Total <br />12. Unit <br />79 <br />HM <br />and Packing Group (if any)) <br />Quantity <br />Wt.Nol. <br />13. Waste Codes <br />No. <br />Type <br />at <br />X <br />ON 1660 Waste Potassium cyanide, solid, 6. 1, 1 RQ ,(Potts) <br />141 <br />p649 <br />0063 <br />001 <br />DF <br />000S3 <br />Z <br />2. <br />W <br />ID <br />3. <br />4, <br />14. Special Handling Instmctions and Additional Information <br />Mill) ERG:157 1 N 2 30 %1 <br />15. GENERATOR'SIOFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment am fully and accurately described above by the proper shipping name, and are classified, packaged, <br />marked and Iabeledlplacarded, 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 that the contents of this consignment conform to the terms of the attached EPA Acknowledgment 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 W <br />generator) is e. <br />GeneratoesrOfferors PdntedrTyped Name a on ay Year <br />Lott <br />K.4c�'IlVg4Afi-wA— is 10 109 <br />i <br />16. International Shipments <br />❑ import to U.S.❑Exp U.S. Part <br />— <br />m entry/exit: <br />Transporter signature for exports only): eleavin U.S.: <br />,d <br />17. Transporm-Acknowledgmenl of Receipt of Materials <br />O <br />Transporter 1 Pdntedrryped Name Signature ont ay ear <br />CL <br />�taaMls �tw� 1 (0 09 <br />4 <br />Transporter2 PdnledRyped Name Signature Mon2ty Day Year <br />K <br />r <br />} <br />18. Discrepancy <br />18a. Discrepancy Indication Space ❑ Quantity ❑ Type YP El Ret ❑Partial Rejection El <br />Full Rejection <br />Manffesl Reference Number: <br />186. Alternate Facility (or Generator) U.B. EPA ID Number <br />J <br />U <br />a <br />ri <br />Faali 's Phone: <br />-(or <br />W <br />18c.Signature of Alternate Facility Generator) <br />Monro Day Year <br />Z <br />Z <br />W <br />19. Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste treatment, disposal, and recycling systems) <br />O <br />1' <br />2 <br />3. <br />4, <br />20. Designated Facility Owner or Operator: Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a <br />PdntedRyped Name Signature Month Day Year <br />FPA Fnrrn <br />97nn-99 lDa• I -MA DrAln..... _— _�.__i_ <br />"'""" """'""' "` ""'"" DESIGNATED FACILITY TO DESTINATION STATE (IF REQUIRED) <br />