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�� /hoer 9t�3�0 <br /> Please print or type.(Form designed for use on elite(12-pil typewriter.) . Form Approved.OMB No.2056-0039 <br /> UNIFORM HAZARDOUS 1'Generdtw ID Number n 2 Page 1 of 3.Emergeenncy—Reesp/onsae Phare 4.IAsmfas Tracking Number <br /> WASTE MANIFEST Ct- DOO dl� d "/DO- 010875076 JJK <br /> 5.Generators Name and ling Address Generabr's Site Address lb different am noting address) <br /> SCS 22�j r11 I!g <br /> 2227 5 5n�la/t / /�y �bn GQ 95aIS <br /> Generators Phorme: <br /> 6.Transporter 1 Company Name U.S.FPA ID Num <br /> ECS (z�Fr n i n CA 003 lO3 5 qa' <br /> 7.Trarapo,er2 ompanY Noy" <br /> o <br /> 8.Designated Faculty Name and IteAddress U.S.FPAIDNumber <br /> Glelrn HiarbPrx <br /> 0,5V "fk ern 1217 ,ru n cu ill vw 9 32d(o M 990 G 9S c274 <br /> Fecal'a Ph., 601 ?boZ,, -oma <br /> ger_ IW.U.S.DOT Description(Including Proper Shipping Name,Hamrd Class.ID Number, 18.Containers 11.Total 12.Unh 13.Waste Codes <br /> FRA and Peeking(roup(if any)) No. Type Quantity WtNnl. <br /> Non WC+4# nus waste 4 <br /> 1 V / <br /> w 2 <br /> 4. <br /> Z <br /> w _ _ <br /> I <br /> n 1 <br /> r n <br /> I <br /> 14.Special Handug lmimcdons and dwruu lrloaton r SS ((,'4 (003o91 <br /> /VWLp,•,GnVI/ yVn(�y 'yyl� (l t.JC•��/�( <br /> 15. GENERATOR'SIOFFEROR'SCERTIFI ON:I hereby declare that the contents of this consgnmentare fully and accurately described above by the proper shipping name,and are classified,packaged, <br /> marked and Izbeledlplacarded,and are in all respells in proper codtion for transport according to applicable international and sunburst governmental mg"dons.It expert shpment and I am the Primary <br /> Exporter,I ceNly Nal the contents of this consignment conform to de icons of the aaarhed EPA Ad mowledgment of Consent <br /> I ceddythat the waste minimlzation statement Identified In 40 CFR 26227(a)(i I am a lame quantity genelator)or am a small quantity re w)is true. <br /> Gwremters'OHe "ntedRyped Nana Signature y Year <br /> e- <br /> J 16.International Shipments; LJ 4portb U.S. ❑Equod U.S. Pod of ed <br /> 1— - Date lea .5.: <br /> E Transporter signature(for exports only): <br /> w 17.TranspodarAcknowiedgment of Receipt of Materials <br /> Transpatzr 1 Prinwayped Name <br /> Signature <br /> /Dray Year <br /> 0 �irn 3 l I <br /> 6 <br /> Q Transporter 2 Prntedriyped Na - Month my Year <br /> 0105r <br /> 1 ' <br /> 16.Discrepancy .. <br /> laz.Discrepancy Indication Space [:] Guam,fi ❑T ❑Partial Rejedlon ❑Full Rejec9an <br /> est Reference Number: <br /> 18b.Alternate Faciily(or Generator) '.HIU _, !?r U.B.EPAID Number <br /> J <br /> aENVIR0NMEY,AL fIE"I' <br /> ori Facility's Atmore: <br /> w 18c.Signature of Alternate Facilty(wGenerator) F=Efi!I�IT/$E!i.`:vE_� Month ow—y", <br /> 6 <br /> 2 <br /> 19.Hazardous Waste Report Management Method Codes(.e.,codes for hazardousndous waste beatmerd,disposal,and recycling systems) <br /> C 1 2. <br /> 3. 4_ <br /> 132 <br /> 20.Designated Facility Oaner or Operator.Cedlficaaorl of raceipt of hazardous materials covered by ge merriest in Item .a <br /> mteMYp reWre Month rYear <br /> EPA F=870 22(Rev.3-05) P w os edit'ans areo lete. E NATE FA LITY TO DESTINATION STATE (IF REQUIRED) <br />