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r. • • t l i <br /> r type.(Form designed foruse onelite(12-pitch)typewriter.) L•<:I+fin - _! Form Approved.OMB Nor.2050-0039 <br /> s WORM HAZARDOUS 1 C',gneialor ID Number 2,Page 1 of 3.Emergency Response Phone - -'4:MbnifeslTraoking Number <br /> WASTE MANIFEST [ � 14 W300 JJ K <br /> 1 ! 1:•S(pt7. ; 1 001827284 <br /> 5.Generator's Name and Mailing Address <br /> 0`LU��fr �2j 1pnr, �, �,,J,(� e a�r5.5ila Address(it ditlerenl than mailing address) <br /> Gen tai's Phone:n� x�.r (',.i --'- 77 <br /> 6.Transporter i Company Name - U.S.EPA ID Number <br /> 'AIdiT 'IT:2f1 Fe;ti3T'x11715#,`dl'tiil 5tie'Y14',r«fi - r.1UNutttiest <br /> 7.Transporter 2 Company Name - U.S.EPA ID Number <br /> PSS, to ilurt;ial 4lutsourDipaa3, 10c. c Fi�[Rt(r3775�7 <br /> B.Designated Facility Name and Sde Address Number ID EPA A <br /> U.S.2'$8t Century, <br /> PAI .. .. <br /> .2vi'1Fi:5 t7nax�.xaTs9� C?a-ii:+#r 3=�t,C <br /> FadlirysPhone: 776_67647790 t4fJ5 C"ct <br /> ~33F <br /> ga. 91b. DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers <br /> HPacking and Racking Group(if any)) 11.Total 12.Unit No13.Waste Codes <br /> 0 f/��� �"✓'Al'°i .�{ , �V6ir/�l. . TYPe Quantity WLNd. � <br /> X00 ja aa� <br /> w <br /> f l/ � <br /> 3. <br /> 4. <br /> z <br /> 14.Sled at Handling InsbOdiolis and digonal Information <br /> �' �/�• Y"/,�-�,w�`,�m �t3 n q� gyp_ /�� <br /> 15. GENERATOR'SIOFFEROR'S CERTIFICATION: 1 hereby declare that the contents of this consignment are fully and accurately desuibed above by the props 1pping name,and are class16ad,packaged, <br /> marked and lateeledlplacarded,and are In all respects In proper condition for transport according to applicable International andnationalgovernmental regpladons.If export shipment and'1 am the Primary <br /> Exporter,I rattly that the contents of this consignment conform to the terms of the attached EPAAcknovdedgmenl of Consent <br /> iqerOy at the waste minimization statement Identified in 40 CFR 262.27(a)(If I am a large quantity generator)or(b)lift am a smal quantity genemt r)is e.. - <br /> .an ORemfs Pdnted?yped Nam Signature Month DaY Yea <br /> —r 16.Intemagonal Shipments ❑ <br /> Z ImportIoU.S. - ❑Export from U S Pod of enbylexit a <br /> Transporter signature(for exports ony): Date Leavj U.S.: <br /> WW 17.TransporterAcknomedgment of Receipt of Materials - <br /> K T ansporter 1 Pdnle ped Name Signature ,/ j/ F. r - - Month Day -Year <br /> z Trans 2 Printed/Typed Name - Si <br /> 99urs _ -_ Month - Day Year <br /> 1B.Discrepancy —_ <br /> Ise.Discrepancy Indication Spars ❑ Quantity ❑Type ❑Residue ❑Partial Rejection ❑Full Refection <br /> Manifest Reference Number. <br /> iBb.Alternate Facility(or Generator)- I U.S.EPA ID Number <br /> J <br /> U <br /> LL Facilly's Phone: <br /> a16c.Signature ofNtemate Facility(or Generator) Month Day Year <br /> z <br /> 19.Hazardous Waaste/Report Management 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 asnded in Item 18a <br /> Pdntedfryped Name (( , )' Signaturek <br /> —`� / <br /> "�� �x.7', ��—�d 1'1'1: f'�Y j ?,.,• j Year <br /> onih DaY <br /> G <br /> 'cbA r__—A en m...�-m n_..v_..: - t' �-l'.•1.._ ...ti /�•.tir-..'l t-l:� U U , �'! <br />