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Please p0afrenype. (Form desioned for use on elite '19 -inti ro�on - • L-1.0111161-,,viev. o-05) Previous editions are oosoiem. DESIGNATED FACILITY TO GENERATOR Form Approved. OMB No. 2050-0036 UNIFORM HAZARDOUS 1. Generator ID Number 2. Page 1 of 3. Emergency Response Phone 4 Manifest Tracking Number WASTEMANIFEST _ _ 6DU-3,4J6>''�':3+� FLE 5.Generator's Name and Mailing Address Generaors Ste Address(i( different than mailing address) - Generators Phone: 6. Transporter 1 Company Name U.S. EPA ID Number 7. Transporter Company Name U.S. EPA ID Number 6. Designated racrfiy Name and Site Address _ U.S. EPA ID Number Facilitys Phone: r ga 9b. U.S. DOT Description (including Proper Shipping Name, Hazard Class, ID Number, 10. Containers 11. Total 12. Unit HM and Packing Group (if any)) Quantity Wt.NoL 13. Waste Codes No. Type �{ f7 Z 2. w 3. 4. 14. Special Handling Instructions and Additional Information - .. y� A' L. I -'R ✓ eY cf(` 4 C.S) !i .� U..3 t ' fF j d ��.i� 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 classified, packaged, _ marked and labeled/placarded, and are in all respects in proper condition for hanspon according to applicable international and national governmental regulations. ff export shipment and 1 am he Primary Exporter, I certify that the contents of this consignment conform to the terms of the allached EPAAcknowledgment of Consent I certify that the waste minimization statement identified in 40 CFR 262.27(a) if I am a large quantity generator) or (b) (if I am a small quamky generator) is uue.. - Genemtors/Offerors PnnhdlTypetl Name - gnature� on ay ear i �+;! f� d.._YJ h� sy x ar__ ✓4 L,f'.- u 1 pz ill -J16. International Shipments ❑Import to U.S. ❑Export i from U.S. Port of entrylextl: Transporter signature for ex its only):Doh Ii U.S.: f - w 17. TmnsporterAcknoWedgment of Receipt of Materials OTransf y PrintetllTyped Name Ignati MonthDay Year I k' Transporter PdntedRyped Name Signature • Month Year yDay 18. Discrepancy 18a. Discrepancy Indication Space ❑ ❑ Partial Rejection Quantity Type El 1 ❑Full Rejection Manifest Reference Number. 1= 181b. Alternate Facility (or Generator) - - U.S. EPA ID Number J V Q LL ` w Feel hoe Sre ofAlhrrate Facility (or Generator) -Monts Day Year 4 z y19. Hazardous"Waste Report Management Method Codes (i.e., codes for hazardous waste treatment, disposal, and recycling systems) w D 1 ' 2. 3. 4. 20. Designated Facility Owner or Operator: Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a PnntedlTyped Name Signature Month Day Year. L-1.0111161-,,viev. o-05) Previous editions are oosoiem. DESIGNATED FACILITY TO GENERATOR