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Pleas^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 F4—Manifest Tracking Number <br /> WASTE MANIFEST ,'�L 1 2Q Q (p f > 3��.�2Z 000928144 F L E <br /> 5.Generaloes Name and Mailing Address, Generators Site A ess(if dlfterant than mailing a ress) <br /> P.p. tf3ox s'�9 <br /> Lo-t l.�o f1 r <br /> to <br /> Generators Phone: -0s63-337 <br /> 6. ransporter 1 Company Name!` U.S.EPA ID Number <br /> % pp <br /> o.ts o—Y- GAk0000-70_-.!; <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> ewD <br /> 0.Designated Facility Name and SileAddress / US.EPA ID Number <br /> ,6;'ed- o CLF,"L-01 <br /> ^-IOnr /•fir <br /> Facility's Prone: <br /> ga 9b.U.S.DOT Description(inclvding Proper Shipping Name,Hazard Class,ID Number, 10.Contafners N.Total 12.Unit <br /> 13.Waste Codes <br /> HM and Packing Group(d any)) No. Type Quantity wtml. <br /> UA!12 elf�nx rr��olQ s{ 1/0�sf VObt 3l <br /> z 2. <br /> LU <br /> C') <br /> 3. <br /> 4_ <br /> 14.$pedalHandling tnstruc4ons and Additional Information <br /> I)sve- got r a012t 003, 004, 00st NIK s0-1 (`7x 4f Y6) 0131x-205.3 t5�e6 1.28 <br /> 15. GENERATOR'S(OFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accuraMly described above by the proper shipping name,and are classified,packaged, <br /> marked and fabetedlplacarded,and are In all respects In proper condition for transport according to applicable International and national govemmenW regulations.If export-shipment and I am the Primary <br /> Exporter,I certify drat the contents of his consignment conbrrn to the terms of the attached EPA Acknowledgment of Consent <br /> I certify that the waste minimization slatemenl Identlfied In 40 CFR 262.27(a)(I 1 am a large quantity generator)or(b)(d I am a small quarillity generator)Is true. Of <br /> oSd p ` Month ay Year rMo' g12o <br /> 16.International Shipments <br /> tm A to U.S. <br /> {, ❑ po ❑Export from UV Port of entrylexil: <br /> ? <br /> Transporter sinature for exports ori : Date leaving U.S.: <br /> W 17.Ti anspatterAdtnowledgment of Receipt of Materials <br /> r Tran 1 P nle yped nature f on ay Year <br /> O r <br /> r 1z�17. <br /> a ta. <br /> Q7porter nt yped ame re Month Day ear <br /> M <br /> 8.Discrepancy <br /> 18a.Discrepancy Indcation space ❑ Quantity ❑P,)* ❑Resldre ❑Partial Rejection Full Rejection <br /> Manifest Reference Number. <br /> .18b.Alternate Feciily(or Generator) U.S.EPA ID Number <br /> U • <br /> W <br /> FadfitysPhone: <br /> w 18c.Signature of Alternate Facility(or Generator) Month Oay Year <br /> z ' <br /> m19.Hazardous Waste Report Management Method Codes(i.e.,codes forhazardous waste treatment,disposal,and recycling systems). <br /> 0 1.-. . <br /> 0� <br /> 20.Designated Facility Ovmer ar Operator:Cerificatbri of recetptof hazardous materials covered by the manifest except as noted in Item 1 a <br /> PrhrtadfT—M Name {S - SI Month Day Year l _—A-t)� ' -tsj A <br /> U <br /> EPA Form 8700. 2(Rev.M5) Previous eden's are obsolete. DSI NATE-FACILITY to pESTINATION STATE(IF REQUIRED) <br />