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% <br />Please print or type. (Form designed for use on elite (12Ditch)tvoewnter.I <br />ti <br />un, vun mvv-c4lVcvwet'rimiwaSmuuua mCLU3VIelG:- <br />DESIGNATED FACILITY TO GENERATOR <br />UNIFORM HAZARDOUS 1. Generator ID Number <br />2. Page 1 of <br />3. Emergency Response Phone <br />row rvi.nw. u. umrx IYu. eu Uuu e <br />4. Manifest TrickAg Number <br />001382396 1 I V <br />NN I� <br />5. Generelors Name and Mailing Address Generators Site Address (if different than mailing address) <br />`. J•`..' <br />Generators Phone - '`'� <br />6. Transporter 1 Company Name <br />U.S. EPA ID Number <br />7. Transporter 2 Company Name U.S. EPA ID Number` <br />8. Designated Facility Name and Site Address U.S. EPA ID Number <br />Facility's Phone: -n tl _•n. _ _ _ _ _ _ _ _ <br />=� I :• ri n Y .� <br />ga. <br />9b. U.S. DOT Description (including Proper Shipping Name, Hazard Class, ID Number, <br />10. Containers <br />11. Total <br />12. Unit <br />HM <br />and Parking Group (t any)) <br />QuanBfy <br />WtNd. <br />13. Waste Codes <br />No. <br />Type <br />K <br />Lfr1:'rf-FJ(::. • .. rl e7 -3,d ijS <br />ag <br />- <br />Tc <br />'140t,,fJ <br />F <br />z <br />W <br />2. <br />3. <br />4. <br />14 Spedab <br />Handl Instructions and Additional lnformon <br />_al <br />_ 1.- - hi -A'S <br />1^L r.:'!T eRC -M-7V! -- <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 class ted, packaged, <br />marred and labeled/placarded, and are in all respects in Koper condition for transport according N applicable international and national governmental regulallons. H export shipment and I am the Primary <br />Exporter, I cedtiy that the contents of this consignment conform to the terms of the attached EPAAcknoMedgment of Consent <br />I certify that the wash minimization statement identified in 40 CFR 262.27(a) (f I am a large quantity generator) or (b) (I I am a small quantity genera ) is true. <br />Genera s/O1Re_roN rs Prn �,Name�j� -•-�- jam% %Day Year <br />V'`�i W� `,`3l�..Ja <br />16. International Shipments <br />❑ Import to U.S. ❑Export � <br />_ <br />bora U.S. Pod ofentry/exit <br />Transporter signature (for exports only): Data leaving U.S.: <br />W <br />17. TransporterA&j*Wedgment of Receipt of Materials <br />Transpader 1 n /y�/ _Namf Sgnature �- c MopN year <br />Transporter 2 Pnnted/ryped Name Signature Month Day Year <br />K <br />F <br />} <br />18. Discrepancy <br />I18a. <br />Discrepancy Indication Space ❑ Quantity ❑ Type ❑Residue ❑Partial Rejection ❑ Full Rejection <br />Manliest Reference Number: <br />18b. Alternate Facility (or Generator) <br />J <br />U.S. EPA ID Number <br />V <br />LL <br />Faciltys Phone: <br />u, <br />led. Sgnature of ANemate Facility (or Generator) Month Day Year <br />Q <br />2 <br />19. <br />Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste treatment, disposal, and recycling systems) <br />p 1. <br />2. 3. <br />4. <br />20. <br />Designated Facility Owner or Operator. Certification of receptof hazardous materials covered by the manifest except as noted in Item 18a _ <br />Pnntedrryped <br />1 <br />Name Signature Month Day Year <br />P, ss—" -f7"` d'1 z t <br />a o 7 h- e� <br />un, vun mvv-c4lVcvwet'rimiwaSmuuua mCLU3VIelG:- <br />DESIGNATED FACILITY TO GENERATOR <br />