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Please print or type. (Form designed for use on elite (12 -Ditch) tvoewriterl <br />. <br />UNIFORM HAZARDOUS 1. Generator ID Number <br />2. Page 1 of <br />- tEmergency Response Phone <br />^ ^r•r�•=� ..,nu ivv. cvvvvwa <br />4. Manifest Tracking Number <br />WASTE MANIFEST - - <br />017'] lrl3 J J K <br />•a.v T 1` <br />5. Generators Name and Mailing Address Generat=es SAeAceress(ddiffr tfhanmailingaddresa) <br />iFii<81t,i iF <br />r r•.:H rte.-; <br />Generator's Phone:, . <br />6. Trensporer 1 Company Name U.S. EPA ID Number <br />7. Transporter 2 Company Name U.S. EPAID Number <br />8. Designated Facility Name and Site Address U.S. EPA ID Number <br />,•apAr7:J fid'9F(,NNi-K".FIT•I Stf•:'$i.4 ,li3z. <br />'Is <br />15 `+EA+IT!1l i i=P PO <br />Fac9ity's Phone:'' <br />9a <br />9b. U.S. DOT Description (inducting Proper Shipping Name, Hazard Class, ID Number, <br />10. Containers <br />11. Total <br />12. Unit <br />HM <br />and Packing Group (if any)) <br />Quantity <br />WLNcl. <br />13. Waste Codes <br />No. <br />Type <br />I . eft rid Et1.., ryn.; ••Fib d7, :,; .. ,Ir :.. fli .VI a.`1Ri <br />7-.' <br />O <br />_ <br />Z <br />w <br />r7 <br />2. <br />3. <br />4. <br />14. Special Handling Instructions and Additional InformaliDn <br />F,F17A. 1 + t :-1-1 <br />F. f—f: r.. 1-1,I'MP HJ11,111i <br />Il FII-' ' WED -PND f t5E r%.1 9'• •L O F'pE <br />15. GENERATOR'SIOFFEROR'SCERTINCATION: I hereby declare that the contents of this consignment am fully and accurately described above by the proper shipping name, and are classified, packaged, <br />marked and Iabeledlplaarded, and are in all respecls in proper condition for transport according to applicable intsmationaland national governmental regulations. If exportshipment am I am the Primary <br />Exporter. I cedity that the contents of this consignment conform to the terms of the attached EPAAclaovdedgmentof Consent <br />I certify that the waste minimization statementidentified in 40 CFR 262.27(a) (H I am a large quantity generator) a (b) (XI am a small quantity generator) is true. <br />GeneraloesfOlferors PrintedRyped Name Signature Month Day Year <br />J <br />16. International ShipmentsF ❑Import to U.S. Expert them U.S. Pod <br />ofenirylexih <br />Transporter signature ifor exports oN$ Date leaving U.S.: <br />w <br />17. TrenspoderAcknowledgment of Receipt of Materials <br />Transporter 1 Pdniedffyped Name Signature - Month Day Year <br />O <br />a <br />N <br />z¢ <br />Transporter 2 PdntedRypetl Name 'Signature - Month Day Year <br />of <br />r <br />.{ <br />18. Discrepancy <br />18a. Discrepancy Indication Space F-1Quantity❑❑ <br />tiType Residue ❑ Partial Rejection El Full Rejection <br />Manifest Reference Number. <br />186. Alternate Facility (or Generator) <br />J <br />U.S. EPA ID Number <br />V <br />Fatility's Phone: <br />w <br />18c. Signature ofAltemate Facility (or Generator) Monm Day Year <br />4 <br />z <br />ti19. <br />Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste treatment, disposal, and recycling systems) <br />D <br />1 <br />2. 3. <br />4, <br />20, Designated Facility Owner or Operator. Certfication of receipt of hazardous materes revered by he manifest except W noted in Item 18a <br />yll <br />can. <br />Pdmedrfyped Name Signature Month Day Year <br />v...., o>rm rte ro_.. n nc� n-_.:_.._ _��___ <br />�.. <br />GENERATOR'S INITIAL COPY <br />