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Plane print or type. C <br />EPS Fort. W .22 (R 1�- 7 Prli#us editions are obsolete. <br />GENERATOR'S INITIAL COPY <br />1. Generator orm pproved. 010B No, ekjDu-u;),)u <br />UNIFORM HAZARDOUS ID Number 2. Page I of 3. liry�c 4. —Manifest Tracking Number <br />WASTE MANIFEST 0 6716, <br />.5 Generator's Name and Mailing Address Generators Site Address (if different than mailing address) <br />-2ene!atoes Phone: <br />Tww;Tter 1 Company'Name• U.S. EPA ID Number <br />h, <br />ra poa,,Nome <br />,,2C, wv U.S. EPA ID Number <br />8. Designated Facility Nan* and Site Address U.S, EPA 10 Number <br />133 <br />Facility's Phone: <br />93, <br />9b. U,S. DOT Description (Including Proper Shipping Name. Hazard Class, ID Number, <br />12. Unit <br />HM <br />and Packing Group (if any)) <br />VA,Vol. <br />13. Waste Codes <br />No <br />T%1P, <br />0 <br />U.1 <br />Ljj <br />4. <br />14. Special Handling Instructions and Additional Inf(wmalion <br />retatt)ed by qeneratc— <br />miid fir suh-tit-u,lc- <br />!5 GEN ERATOR'SIOF FEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by the proper shipping name, and are classifed. packagiic, <br />marked and labeled/placarded, 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 AcknaModgment of Consent. <br />I certify that the waste minimization statement identified in 40 CFR 262.27(a) (IT I am a large quantity generator) or (b) (iff am a small quantity generatori is true. <br />Generators/Offeror's PwintediTyped Name Signature Month Day Year <br />-j <br />16,IntemationalShipments; <br />❑ Import 10 El <br />U.S, Export from U S. Port 61 ertryiexii: <br />Transporter signature (for exports only): Date leaving U.S.: <br />ad <br />w <br />17. Transporter Acknowledgment of Receipt of Materials <br />. <br />I-- <br />M <br />I . ; ii ipodef I PrintedrTyped Name Signalurei.' Month Day Year <br />0 <br />Elf) <br />r <br />Z <br />$porter 2 PrintediTyped Name Signature Month Oay *ar <br />I& Discrepancy <br />18a. Discrepancy Indication Space El Quantity ❑ Type ❑ Residue El Partial Rejection 0 Full Rejection <br />Manifest Reference Number: <br />18b. Alternate Facility (or Generator) U.S. EPA ID Number <br />U<. <br />Facifitys Phone: <br />C3 <br />—18c. Signature ofAltemate Facility (or Generator) <br />MGrm Dav Year <br />Ac <br />Z <br />19. Hazardous Waste Report Management Method Codes (i e codes for hazardous waste treatment, disposal, and recycling systems) <br />120. Designated Facility Owner or Operator: Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a <br />IPrintedirTyped Name Signature Month Day Year <br />EPS Fort. W .22 (R 1�- 7 Prli#us editions are obsolete. <br />GENERATOR'S INITIAL COPY <br />