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Please print or type.(Form designed for use on elite(12-pitch)typewriter) - Form Approved.OMB No.2050-0039 <br /> UNIFORM HAZARDOUS 1.Generator ID Number 2.Page 1 of 3 Emergency Response Phone 4.Manifest Tracking Number <br /> 1. ' <. ryr� (� !r•e. �'hr t <br /> WASTE MANIFEST - ' - Cf .J el' (} FLE <br /> FUNIFORM <br /> Generators Name and Mailing Address Generators Site Address(if different than mailing address) <br /> Generators Phone: <br /> fi Transporter 1 Company Name _ 3 U.S,EPA ID Number <br /> 7.Transporter 2 Company Name NOV Q U.S.EPA ID Number <br /> 8.Designated Facility Name and Site Address - <br /> US EPA ID Number <br /> t xss{-Fak wz�lt x,a3 be=Elk: ENTAL HEAL <br /> I.€.�sMffaiIll r�AatE iZcew4' ENVIRpNM �, ; C+ .3?':: e �;° <br /> rr;�tis s .VT 029 �EFARTMENT <br /> Facility's Phone: ,e've 13'4.1100 <br /> 9a, 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit <br /> HM and Packing Gmup(If any)) No. Type Quantity Wt.NLo13.Waste Codes <br /> � i.4�4�4 a€L [ .].}i cep e4�.,,?• rr r C.J t... <br /> 3 !7f- 7�.'A'fv 1TE. 13:'ritiislW€'r,A .utL F _ <br /> 4. n _ <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 dassified,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 contents of this consignment conform to the terms of the attached EPAAcknowledgment of Consent r', . r r,. <br /> I cedify that the waste minimization statement identigje,Qjn 40 CFR 262.27(a)(If I am a large quantity generator)or(b)(if i am a small quandty generator)is true.d(,- <br /> Genemtoes/Offerg�,sPriRtedrFyped Name bignil *- �._ a Wainay Year <br /> i6.International Shipments - <br /> p- ❑Import to U.S. ❑Ezpod from U.S. Port ofentiylexiC <br /> Transporter si nature for exports only): Date leaving U.S.: <br /> w17,Transporter Acknowledgment of Recelptof Materials _..,.�, <br /> Transporter 1 of d`/fn- al Nie.F„ // Signs ure onto Day ear <br /> uo <br /> Transporter 2PrintedRyped Name - Signature ` Month Day Year <br /> C ' <br /> F- <br /> 4. 18.Discrepancy <br /> 18a.Discrepancy Indication Space ❑ Quantity ❑Type <br /> ❑Residue ❑Partial Rejection ❑FWI Rejection <br /> Manifest Reference Number: <br /> F 18b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> J <br /> U <br /> Q <br /> LL <br /> Facility's Phone: <br /> w 18c.Signature of Alternate Facility for Generator) Month Day Year <br /> a <br /> z <br /> .� 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> 1. ii:'i.'€Q} 2. l.; ;.4 3. ..{'i+rn{` 4. <r <br /> (` 20.Designated Facility Owner or Operator.Cerdfication of receipt of hazardous materials covered by the manifest except as noted in Item His <br /> 1-11 typed Name Signature Month Day Year <br /> EPA Form,8 0JR.J5evW4 5),P ecus a '%s eregbso(ill gin Nii €I r?asFp.e SF: x .v 44t4r 2b <br /> GENERATOR'S Aara r.c±rkgisxi-;. GENERATOR'S INITIAL COPY <br />