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Reasiprinl or type,(Form designed for use on elite(12-pitch)typewriter,) Form Approved.oms No.2050-0039 <br /> DOUS t-Generator10 Number 2 Pagel of 3 Emergency Response Phone cking Number <br /> 14.Manifest Tracking UNIFORM HAZAR <br /> WA$Tf MIANIKST <br /> -)W '90,r8 I SKS <br /> 5,GerteratWes Name and Mailim Address Generator's&teAddress(if diterePt than mailing address) <br /> �,1CH.YA '�Fx 6�i <br /> Gerieral!(Ys Phone: <br /> 5.Tran <br /> ,!pqrter I Company Name U.S.EPA 11)Number <br /> 7,Transporter Z Company Name U.S.EPA 11)Number <br /> 8,Designated Far.AilyNamearid SMAddressFE 'I <br /> U.S.EPA JO Number <br /> T Y.– t'.EC'N S;Y$TEM !W- <br /> .,4 <br /> Qoo se si r,krr <br /> f ct <br /> Facilil(a Phone: <br /> go. 0.Q.S.DOT Description finclveing Proper Shipping Name,Hazard Class,fD Nvm* 10.Containers 11.Total 12.Unit <br /> HM and Packing Group(T any)) No. Type QuantityVVIrNol. 13.Waste Godes <br /> PAAT-Fi V3ACHV.R 3DUTIC40 <br /> LU <br /> 3. <br /> 4. <br /> 14.Special HandlIng InSlUtIons and jZ'dditional In <br /> "-B'Dn <br /> s uzf wo S1,3' <br /> 15. GENERATORSOFFEROR'S CERTIFICATION;I hereby declare that 4hL%OMIM of this consignment are fully and accurately described above by the proper shipping name,and Are classified.packaged, <br /> maiked and Iabeled/ptacarded,and ore in all respects in proper condition for transport according to applicaUe infamAlJonal and national governmental mgulallons.If export slipment and I am the Primary <br /> Exporter,I 09ilify that the contentis of this consignment conform to the terms of the attached EPA Acknowfedgment oi.Conscril. <br /> I artily that the waft minimizaVon statement identified 10 40 CFR 262,27(1)(if!am a large quantity generator)or(b)lift am a small qua", -jsn9NLor)is true. <br /> Generaloes/Offera(s Prinledffyped Name Signature. 11. Month Day Year <br /> 4 <br /> 16.Int ;%; ShOments <br /> ❑Import 10 U.S. Export from 0, Pao of orllry/ev� <br /> TfailSpOftr SigAaltl(6(for eVorts only): Date leaving, .S.: <br /> 17.Trarsporter AcluxWedgment of RPAcqip[of Matedals, <br /> TranaporteJ u <br /> j= Me <br /> rinledrlyped N Signature Month Day Year <br /> <:Z Transoorter 2 PrintedfTyped Name SgneCUie, Month Day Yes <br /> ce <br /> It= <br /> 118.D'crepanq <br /> I$a,Mscrepanoy IndimAtior Spam Ej Quantity E]TM 0 Re-ildue EJPrfi.I Rejttion Elvi Reiev;on <br /> I <br /> Manifest Reference Number. <br /> g= 18h.Alternate Facility(orGenerator) U.S,EPA ID Number <br /> LL Forility'n Phone: <br /> 18c.Signature ofAltemate Facility(or Gmeralor)_ Mort Day Year <br /> g5 19.Hazardous Waste Report Management Malliod Codes(i.e..codes for hazardous waste treatment,disposal,and recycling systems) <br /> LLJ f. 2. 3, 4. <br /> dn <br /> F1 1�1e,,p�lpdity Owner or Operator:Cer0calon of receipt of haz2ous materiah,covered by the manifest excepl.psjnoled in 1ern 18a <br /> prm,l N7 Signature.+' r' Worth Day If <br /> A <br /> 41 <br /> !r6.r <br /> 899-3 TZO/Md O6E-1 OT ,-81-10 <br />