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<br /> Please print or type.(Form designed for use on elite(12-pitch)typewriter.) t Form Approved.OMB No.2050-0039
<br /> UNIFORM HAZARDOUS I'l.Generator ID Number 2.Page 1 of 3.Emergency Response Phone 4.Manifest Tracking Number
<br /> WASTE MANIFEST ( r1'1 Vi a-' . "'l . / f i, x"�_ (i t 0 _r , ,.3.1'J'- ).
<br /> 5.Generator's Name and Malting Address Generator's Site Address(I different than mallinig address)
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<br /> Generator's Phone: .1ta.r !+•I(:1+1l�
<br /> 6.Transporter 1 Company Name U,S.EPA ID Number
<br /> 7.Transporter 2 Company Name U.S.EPA ID Number `
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<br /> 8.Designated Facility Name and Site Address U.S.EPA ID Number .
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<br /> Fadliy/s Phone: "'+Y +f i t 1=
<br /> ga. 9b.U.S.DOT Description(Including Proper Shipping Name,Hazard Class,ID Number, 10,Containers 11.Total 12.Ung 13.Waste Codes
<br /> HM and Packing Group(it any)) No. Type Quantity Wt.N01.
<br /> O 1. ,I,.516:•;',,( 'i','.i 1 21 t���,tf 1•i tF£ 1�r i:j,LO,r•sv r btt- t:'� 1 i,
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<br /> THIS WASTE STREAM I•IAS I3EEPd 4!l,?l.I�IEU
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<br /> QUALIFIED.OUR I&A NUi,11 %Fi IS CAT080013352
<br /> 14.Special Handling Instructions and Additional Information
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<br /> 15. GENERATOR'SIOFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are fuyiy and decuratety described above by the proper shipping name,and are classified,packaged,
<br /> marked and labeledlplacarded,and are in all respects in proper condition ID,transport according to applicable inlemalfonal 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 EPAAcknoxledgmenl of Consent.
<br /> I certify that the waste minimization statement identified in 40 CFR 262.27(a)(111 am a large quantity generator)or(b)(if team a small quantity generator)Is true.
<br /> GeneratoeslOfferoes Prinled/ryped Name Signature l Month Day Year+
<br /> J 16.International Shipments Import to U.S. ❑Export from U.S. Port of entrylexit:
<br /> Transporter signature(for exports only): Date leaving U.S.:
<br /> w 17.Transporter AcknoMedgment of Receipt of Materials
<br /> Transporter 1 Printed(Typed Name Signature••1 Monti Day Y4ar
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<br /> z Transporter 2PrintedlrypedName Signature �' y r yr rh_ l Month Day Year
<br /> � •✓`1 r" i'e f'. �'i s". , 1 i/ , t r j�(�.�_ 1 E � � {/_'�s��..�`� j f' f_��/`' A/
<br /> 18.Discrepancy
<br /> M.Discrepancy Indication Space El quantity ❑Type ❑Residue ❑Partial Rejecton ❑Full Rejection
<br /> Pece• Manifest Reference Number.
<br /> 18b.Alternate Facility(or Generalor) U.S.EPA ID Number
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<br /> LLFacility's Phone:AUG 1 1 2 U 14 f
<br /> W lac.Signature of Allernate FacAty(or Generator) Month Day Year
<br /> CRA INC.
<br /> 19.Hazardous /nos ' .nage ,en ethod Codes{i.e.,codes for hazardous haste treatment,disposal,and recycEng systems)
<br /> w 1. 2. 3. 4.
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<br /> 20.Designated Facility Owner o•Operator:Certification of recelpt of hazardous materials covered by the manifest except as noted in Item lea
<br /> Printed/fyped Name qq p
<br /> r /j_` --- Signature jj _ _ Month Day
<br /> 1Day Year
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<br /> EPA Form 87011-22(Rev.3-05) Previous editions are obsolete. - DESIGNATED FACiLITYTO GENERATOR
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