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Please print or W. (Form designed for use on elite (12-0itchl tvoewdter) <br />UNIFORM HAZARDOUS 1. Generator ID Number <br />2. Pagel of <br />3.Emergehty Response Phrne 4. <br />Manifest Tmcking Number <br />WASTE MANIFEST <br />JJK <br />5. Generators Name and MalltngAddress Generators Site Address (if different ricin mailing address) <br />Generators Phone: <br />6. Transporter 1 Company Name U.S. EPAID Number <br />7. Transporter 2 Company Name U.S. EPA ID Number <br />B. Designated Facility Name and Site Address U.S. EPA ID Number <br />Facililys Phan: <br />9a <br />9b. U.S. DOT Description (including Proper Shipping Name, Hazard Class, ID Number, <br />10. Containers <br />1Quantityl <br />iWtNoL 2 Unit <br />HM <br />and Pad'sg Group (if any)) <br />13. Waste Codes <br />No. <br />Type <br />QO <br />C <br />z <br />2. <br />w <br />t7 <br />3. <br />4. <br />14. Special Handling Instructions and Additional Information <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 labelediplacarded, and are in all respects in proper condition for transport according to applicable International and national governmental regulators. If export sinal and I am the Primary <br />Exporter, I certify that the contents of this consignment conform to the tomo of the attached EFAAcImowledgmentof Consent <br />I cm* that the waste minimtration statement identified in 40 CFR 262.Z7(a) (if I am a large quantity generator) or (b) it am a small quantity generator) is We. <br />Generators/O6emrs Pdntedrryped Name Signature Month Day Year <br />-J <br />16. Intemational Shipments <br />❑Importto U.S. ❑Export from U.S. Pod ofenby/exit <br />Z <br />Transporter signature(for exports only): Date leaving U.S.: <br />w <br />17. Transporter AcknmMedgmentof Receipt of Mate;z <br />Transporter 1 PrudedRyped Name Signature Monro Day Year <br />O <br />CL <br />n <br />Q <br />Transporter 2Printedr7yped Name Signature Monro Day Year <br />K <br />F <br />1B. 0iurepancy <br />19a. Discrepenty Indication Space ❑ Quantity ❑Type ❑ Residue ❑ Partial Rejection ❑ Full Rejection <br />Manifest Reference Number: <br />18b. Alternate Facility(or Generator) U.S. EPA ID Number <br />J <br />V <br />LL <br />Fal Phone: <br />Maj <br />18c. Signature ofAltemate Facility (or Generator) Month Day Year <br />a <br />z <br />N19. <br />Harardous Waste Report Management Method Codes (l.e., codes for hazardous waste treatment, disposal, and recycling systems) <br />4. <br />20. Designated Facility Owner or Operator. Certification of receipt of hazardous materials covered by the maddest except as noted in Rem 18a <br />I <br />Pontedrryped Name Signature Month Day Year <br />cru ronin muv-tt lrcev.,wp1 rrewousegmons are madam. GENERATOR'S INITIAL COPY <br />� <br />/-37i 51 <br />