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<br /> Form Approved OMB No.2050-0039(Expire 30 99f r i { h r See Instructions Qback of Cr b ; a i
<br /> Please print or Mm. Form.'designed'far arse on i6b'j'f,7 p J nPev� £ p ; `1 Deparmtent of Toxic Su6smnces r5 n4
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<br /> -tet 16. G NERATOR'S CERVICATIOk. I hereby declare that the contents of this consignment are Fully and accurately described above by proper shipping nome'o6d:are classified packed
<br /> Vmarked,and labeled and are in all respects in proper condition ror transport iiy highway according to applicable tnternationai and national government regulations it r
<br /> L j �11If 1 am a'large quantity generator,I certify Chet I have a program in place b reduce the volume.and Toxicity of waste gsnerafed so the degree I have determined to lie'economjcclly
<br /> a practicable and.that I have selected Ilse racticable method of treatmrrnt,storage,or disposal currently available to me which minimizes the present and Future threat to human health
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<br /> and the environment;OR,if I am a small quantity generator,I have made a good faith effort to minimize my waste generation and select the best waste management method that is
<br /> 0 available to me and that I can offord_
<br /> } �Printed/yped e. 1 Signature' f y P` n Da ~Year
<br /> au R 17. Trans er 1 Ac ement of Receipt of Materials
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<br /> W_ 0 18. Transporter 2 Acknowledgement of Receipt of Materials
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<br /> 1 20. FacilityOwner or Operator Certification of receipt of hazardous materials covered b this manifest except aa'noted in.ltem 19.
<br /> T- Printed/Typed Name' Signature s t. , q k y Manth Day Year
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<br /> Yellow;:.,, GENERATOR RETAINS
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