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[ TSC fl3 I;f <br /> Please print or type.(Form designed for use on elite(12-pitch)typewriter.) Form Approved.OMB No.2050-0039 <br /> UNIFORM HAZARDOUS 1.Generator ID Number / / 2.Page 1 of 3.Emergency Response Phone 4.Manliest Tracking Number <br /> WASTE MANIFEST C,94000 3SY X66 (,2 L/_36,26—'V 013976240 JJK <br /> 5.Generplors Name and Mailing A�-- ^ � Q T��t/ C �t Ste Address('rf different than mailing address) <br /> -41 IV- <br /> Gefiera�torneq 9J36G <br /> 6.Transporter 1 Company Name U.S.EPA ID Number <br /> P.91—Ri0r 1r'40 0s--3 0 c' 9y <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> B.Desi hated Facility Name and Site Address SQe��r�s U.S.EPA ID Number <br /> �i9/7�S �NviiQGlNiyfoy . <br /> �S�S ,s`_ ,Q iv42 �PoAv <br /> Facility's Phone: <br /> ga 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit 13.Waste Codes <br /> HM and Packing Group(if any)) No. Type Quantity WilVol. <br /> .1-.,VCA/ IQ,-" N�1 ZAP Ax tl �✓�s�Ci L i B�iv DOI `� <br /> • w�a zv/a�.s�%�L <br /> z 2. <br /> W <br /> (7 <br /> 3. <br /> 4. <br /> 14.Special Handling Instructions and Additional Information <br /> , � rJ3 /;;?o.3WR Aw a 54 8�5 33 8 Sv %'C 8 - <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 intemational and national governmental regulations.If export shipment and I am the Primary <br /> Exporter,I certify that the contents of this consignment conform to the terms of the attached EPAAcknwwledgment of Consent. <br /> I certify that the waste minimization statement identified in 40 CFR 262.27(a)(if 1 am a large quantity generator)or(b)(H I am a small quantity generator)is true. <br /> Gen for Offerors PrintedrTyped Name S gnatu Month Da Year <br /> b. <br /> T--r <br /> 16.International Shi menLs <br /> F Import to A. Export from U.S. PaAof enirylexit <br /> Z Transporter signature(for exports only): Date leaving U.S.: <br /> 17.Transporter Acknowledgment of Receipt of Materials <br /> 162nsporter 1 Printedrfyped Name Signature Month Day Yea <br /> a <br /> Z Transporter 2 PrintedTyped tone Signahr Month Day Year <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space Quantity ❑Type ❑Residue ❑Partial Rejection ❑Full Rejection <br /> Manifest Reference Number. <br /> 18b.Alternate Facifity(or Generator) U.S.EPA ID Number <br /> J <br /> U <br /> U- Facfityys Phone: Monro Day Year <br /> W 18c.Signature otAltemate Facility(or Gene ator) <br /> Q <br /> Z <br /> H19.Hazardous Waste Report Management Method Codes(.e.,codes for hazardous waste treatment,dcsposal,and recydng systems) <br /> 0 1 1 2. 3• 4. <br /> b� <br /> 20.Designated Facility Owner cc Operator.Certification of receipt of hazardous materials covered by the manifest except as nded n Item 18a <br /> PrintedT Name Sgrow'e ,/f Mm� Year <br /> EPAForm 00 ed <br /> (Rev. Previou ' ns are ete. DES ATED IF'ACILFrY TO DESTINATION STATE(IF REQUIRED) <br /> 12233.1679 <br />