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• <br /> 410 <br /> Please print or type.(Form designed for use on elite(12-pitch)typewriter.) Form Approved.OMB No.2050-003� <br /> UNIFORM HAZARDOUS 1•Generator ID Number ————F2 �age 1 of 3.Emergency Response- _X) Manifest Tracking Number <br /> A L <br /> WASTE MANIFEST .9W) 42* 311000522715JJK <br /> 5- aridyaiIinq Oq.9% Generators Site Address(if different than mailing address) <br /> �'AC I A C AVE <br /> C,enereWs Phone: <br /> 6.Transporter 1 Company Name U.S.EPA ID Number <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> 8.Designate Facil Name and Site Address U.S.EPA ID Number <br /> Aft TREx <br /> -Alt— <br /> Facilitys Phone: <br /> ga. 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit 13.VVWA Codes <br /> HM and Packing Group(if any)) NO. Type Quantity vvt.fvol. <br /> A <br /> 2. <br /> iii0 <br /> 3. <br /> 4. <br /> 14.Special Handling Instructions and Additional Information <br /> PP 1i. - 'd ,W, gippp")14V.ff- P�:R: )"AM <br /> A.�Imq uln <br /> I X-V�44--TIT <br /> PO#AO80072573 PROJ HB-54506AI2 <br /> 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, <br /> marked and Labeled/placarded,and are in all respects in proper condition for transport according to applicable intenrafional and national governmental regulations.If export shipment and I am the Primary <br /> Exporter,I certily that the contents of this consignmen(confon-n to the terms of the attached EPA Acknowledgment of Consent. <br /> I certify that the waste minimization statement identified in 40 CFR 262.27(a)(it I am a large quantity generator)or(b)(ifi am a small quantity generator)is true. <br /> GoneFaWaKNeroes PriintedfTyped Name Signature- Month Day Yew <br /> C' <br /> _j 16.International Shipments <br /> 1— 1:1 Import to U.S. Eport from U.S. Port of entry/exit: <br /> Transporter signature(for exports only); Date leaving U.S.: <br /> V.Transporter Acknowledgment of Receipt of Materials <br /> Ul ..'. I W_ Year <br /> 12 T er A I Printecirryped Name Signature - Monk % <br /> 4e; <br /> 0 <br /> r <br /> Transporter 2 Printed(Typed Name Signature <br /> Month Day Yew <br /> 18.Discrepancy - <br /> laa.Discrepancy Indication Space ❑ Q.,,nfity El Type ❑Residue ❑Partial Rejection ❑Full Reje8on <br /> Manifest Reference Number: <br /> 18b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> u- Facifitys Phone: <br /> C2 <br /> luj 18c.Signature ofAJtemate Facility(or Generator) Month Day Year <br /> Z <br /> M <br /> 95 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> Uj 1. 2. 3. 4. <br /> 20.Designated Facility Owner or Operator.Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a <br /> PfintedffypLdl Name Signature Month Day Year <br /> PA Form 87IG-22(Rev.3a) Previous editions are obsolete. GENERATOR'S INITIAL COPY <br />