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0 <br /> Form Approved.OMB No.2050-0039 <br /> Please print or type.(Form designed for use on elite(12-pitch)typewrites p Page 1 of 9 Emergency Response Phone 4.ManNest racking umber <br /> UNIFORM HA2AR000S 1.Generator to Number 000 T"q 4 VES <br /> WASTE MANIFEST °"'' <br /> Gzner+icr s 5ne Asd:ess lit tlldemm Nan mailiny address) <br /> 5.Generators Name and Mailing Adcress <br /> Generator's Phone: U.S.EPAID Number <br /> ft Transporter f CoIrpaoy Noma <br /> '— U.S.EPAID Number <br /> L Tra-spomelr 7 0T-Pt m[Name <br /> U.6,EPA ID Number <br /> 8.Designated Facility Name 2no SiteAddresa <br /> Facility's Phone " <br /> 10.Containers 11.Total 14.Unit 16,Worsts Codes <br /> ya So.Vs.DOT Description(including Proper shipping Yoma.Hazard Class.ID Number. No. Type Quantity VVINOI. <br /> HM and Packing Group Qi any)) <br /> K <br /> K <br /> 2 2. <br /> W <br /> 3. <br /> 4. <br /> 14.Special Handling insructrins xnd Ador;ional lnlamta;iun <br /> +.5. GENERATOWMFFEROR'S CERTIFICATION: I hereby declare that the oplames of Ibis annsignmen.are fully and accufztely descdbad above rAshe proper shipping name.,mearid ere Classified,IamhPackaged <br /> marked and IaOeledlpxamed,and are In aU mspecrs{n Pull condition for transport according to applicable imamational and national governmernai rogukations.if axial shipment and am the Primary <br /> Cxpokm r.I certify that the cw:tents of this conslgnmont conform tote terms of the attached EPAAcknowledgment of Consent. <br /> I countythm the waste roiriena inn statement klemified 040 CFR 264.271.)Of I am a large quantity generator)drip)(111am a small quantity ge+mraWr)is tine. Month Day Year <br /> Generatar�femrs Printedtryped Name Siynelu-e <br /> v <br /> J 16 lnternmmnal Smilmentsnpc=,tc U.S. F]Export from U.S. Part of emrylexit <br /> _ <br /> Dale leaving U.S.: <br /> Transporter signature(for expel is onto <br /> O= 17.'rear sporerAcknowladgmem of ReceiplMMatedak Month Day Year <br /> Signamm-r" .,. t <br /> Tlansperisr'.Pnnlad('ypT Name _ <br /> `Q� Spnalure Month Day Year <br /> 2 Traospmter 2 Prr(d4yped Name <br /> TiA.Discrepancy ___... <br /> fAa.Oixuepanc/indication Space I—� �Typa Rescue ❑Pedlal Rejection ❑FW%-It- <br /> _1 Olmnt ry <br /> MaNfest Reference Number <br /> U.S.EPAID Number <br /> Itro Alternate Facitty(Or Generator) <br /> J <br /> W Fatoktys Phone: Month Day <br /> Year <br /> is,Signature of Aunnale Facl".ity for Gerseatnq <br /> 19.Ha2aideus Waste Report Management Method Codes ba.,codas for hazardous waste treatment,disposal,and recycling systems) 4 <br /> 3. <br /> C! ., !t rfF <br /> 20 Designated Facility Owner rr Operator:Comflur on of recept of hautdOOS materials covered by he mandsst except as nded Ir I'Cm 1A:+ Mon Day Year <br /> PnntadrjypM Naha r <br /> J DESIGNATED FACILITYTO GENERATOR <br /> EPA Foml 87Df?2(Rev 3 051 PI awous editions are obsolete. <br />