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Please Drint or Woe <br />A -p p <br />Ert'i r I VV -ZZ tr%Lv. is !)..rrevicius euniciri are ODsoiete. <br />GENERATOR'S INITIAL COPY <br />UNIFORM HAZARDOUS Gunuratcj ID Number 2. Page1 of 3. E umber <br />3� 1� �,Io 14. Manifest Tracking N <br />t'p, ��o <br />WASTE MANIFEST <br />1 006686667 SKS <br />5. Generator's Na me and Matting Address Generators Site Address (if different than mailing address) <br />I <br />Generator's Phone: <br />6, Transporter 1, C.empar <br />7. Transporter 2 Company Name U.S. EPA ID Number <br />8- Desionated Facilq Name and Sfe.Aodibss U.S. EPA ID Number <br />Facilil (s Phone: <br />fla. <br />9b. U.S- DOT Description (including Proper Shipping Name, Hazard Class, 10 Number, <br />10, Containers <br />11. Total <br />12, Unit <br />HMand <br />Packing Group til any)) <br />Quantity <br />M./Val. <br />Q. Waste Codes <br />Na. <br />Type <br />O <br />t. <br />W <br />j <br />i3 <br />14 Spedal Handling instructions andAdditional Information <br />15='ERWT8I1'SIO'FFEROR'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 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 contends of this consignment conform to the terms of the attached EPA AckwAdgment of Consent. <br />I oerfify that the waste minimization statement identified in 40 CFR 262.27(a) (if I am a large quantity generator) or (b) fill am a small quantity generator) is true. <br />Gr eraloi'siOfferoes Printed/Typed Name Signature Month Day led <br />16. Intematiorief Shipments <br />1:1 LWt to U.S. El Export from U.S, Pori of ed( fexit: <br />Transporter signature (for exports only): Date leaving U.S.: <br />17, Transporter Acknowledgment of Receipt of Maleri-315 <br />iter 1 Prin "�iTyped Name Signature Month Day Yeie <br />0 <br />Z <br />tk <br />Transporter 2 Printed/Typeld NameSignature Month Day Year <br />18, Discrepancy <br />18a. Discrepancy Indication Spare Quantity Typ c El Residue ❑ Partial Rejection ❑ Full Rejection <br />Manifest Reference Number: <br />18b. Alternate Facility (or Generator) U.S. EPA ID Number <br />:3 <br />LL- <br />Facility's Phone: <br />I <br />0 <br />U, <br />1 — <br />18c. Signature of Alternate Facility (or Generator) <br />, <br />11r, -,,!n Day Yea; <br />19. Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste treatment, disposal, and recycling systems) <br />in <br />2. 7-1— <br />I <br />4. <br />20. Designated Facility Owner or Operator. Cerfificalion of receipt of hazardous materials covered by the manifest except as noted in hem 18a <br />Printed/Typed Name Signature k!'; ith Day Year <br />Ert'i r I VV -ZZ tr%Lv. is !)..rrevicius euniciri are ODsoiete. <br />GENERATOR'S INITIAL COPY <br />