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• <br />Form ADDraved. OMB No. 2050-0039 <br />a..ve <br />y .... .. I ...... ___, <br />UNIFORM HAZARDOUS <br />__ _. ___ _ _ , _ _ _ <br />1 Generator ID Number <br />_ <br />2. Page 1 of <br />_ <br />3. Emergency Response Phone <br />.. <br />�' <br />4. Manifest Tacking Number <br />0 nd 8�� 3 2 C I C <br />WASTE MANIFEST <br />- - <br />- - -' -' <br />i�S ti E,� ..l r L. C <br />5. Generators Name and Mailing Actress Generators Site Address (it different than mailing address) <br />Generators Phone'. <br />6 Transposer 1 Ccinc ny Name U.S. EPA ID Number <br />7. Transporter 2 Company Name U.S. EPA ID Number <br />S. Designated Facility Name and Site Address U.S. EPA ID Number <br />Facility's Phone: <br />9a. <br />Sb. U.S. DOT Description (mcluding Proper Shipping Name, Hazard Class, ID Number, <br />10. Containers <br />11, Total <br />12. Unit <br />13. Waste Codes <br />No. <br />Type <br />HM <br />and Packing Group (if any)) <br />Quantity <br />WLIVOI. <br />Z <br />W <br />2. <br />0 <br />3. <br />4. <br />14. Special Handling trial lions and Additional Information <br />15. GENERATOR'SIOFFEROR'SCERTIFICATION. 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 certity, that the contents of this consignment conform to the terms of the attached EPA Acknowledgment of Consent. - <br />I ceNfy that the waste minimization statement identified in 40 CFR 262.27(a) (B I am a large quantity generator) or (b) (if I am a small quandly generator) is We. <br />Genemtorsl0fieror's PrintedlTyped Name ngnalure.,h t ziti on ay Year <br />—o— .- ti , '''' `} <br />� <br />o i,.,3 <br />j <br />r <br />y`:: 'f,¢. t _ <br />16. International Shipments' <br />❑Import to U.S.! Export from U.S.SPort of entrylexit <br />z <br />Transporter signature for exports only): Date leaving U.S.: <br />w <br />17, TfansporterAcknowledgmentof Receiptof Matedals <br />Mon a�yyr Year <br />TaosegulI PrimeciTyped Name _ ignature i '� <br />ILS I IBX; <br />`� I =`' --'� i ":n=- �S <br />N <br />z <br />Q <br />.:�— <br />R „� v ! - s - • .�'- p Signature Year <br />Tan _i,..,, <br />sporter2Pdntg[Tyjge�d Name <br />f -.E /i <br />18. Discrepancy <br />18a. Discrepancy Indication Space ElQuantity DType - ❑ Residue ❑ Partial Rejection ❑ FUII Rejection <br />Manifest Reference -Number <br />18b. Alternate Facility (or Generator) - U.S. EPA ID Number <br />J <br />U <br />LL <br />Facili s Phone: _ <br />W <br />18c.SignatumofAlternate Facility(or Generator) <br />a <br />z <br />y19. <br />!Mo!nthD!ay]Year <br />HalardeUS Waste Report Manaeement Method Codes (i.e., codes for hazardous waste treatment,disposal, and recycling systems) <br />2.3. 4. <br />20. Designated Facility Owner or Operator: Certification of receipt of hazardous materials covered by the manifest except as noted in Item IBe <br />PrintedRypad Name Signature Month Day Year <br />—,,.., Ar ee rv.r TM nCk=erne <br />EPA Form 37U1 (Kev. 3-Ub) Envious earners are uusuie,e. <br />