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Please print or type. (Form designed for use on elite (h) tvoewriter.) db" 4 FnrmAnnrnvad 0MRNn gnsnsma trH r-orm uruu-zz (rev. a-uof rrevious ecmuvns are UUSUiere. UNIFORM HAZARDOUS 1. Generator ID Number 2. Page 1 of 3. Emergency Response Phone 4. Manifest Tracking Number WASTE MANIFEST ' FLE 5. Generator's Name and Mailing Address Generators Site Address (if different than mailingaddress) c Generator's Phone. a 6. Transporter 1 Company Name U.S. EPA ID Number 7. Transporter 2 Company Name U.S. EPA ID Number 8. Designated Facility Name and Site Address U.S. EPA ID Number r r., Facility's Phone: ga, 9b. U.S. DOT Description (including Proper Shipping Name, Hazard Class, ID Number, 10, Containers 11. Total 12. Unit HM and Packing Group (if any)) Quantity Wt.Nol. 13. Waste Codes No. Type IX LU Z 2. . , , UW' 1 3. 4. 14. Special Handling Instructions and Additional Information 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, marked and labeled/placarded, and are in all respects in proper condition for transport according to applicable international and national governmental regulations. If export shipment and I am the Primary Exporter, I certify that the contents of this consignment conform to the terms of the attached EPA Acknowledgment of Consent. I certify that the waste minimization statement identified in 40 CFR 262.27(a) (if I am a large quantity generator) or (b) (if I am a small quantity generator) is true. Generato s Offeror's Printed7Typed Name Signature Month Day Year 1— 16. International Shipments ❑ import to U.S. ❑ Export from U.S. Port Z of entry/exit: Transporter signature for exports only): Date leaving U.S.: W 17. Transporter Acknowledgment of Receipt of Materials Transporter 1 Printed/Typed Name Signature Month Day ear O a Cf) Transporter 2 Printed/Typed Name Signature Month Day Year t- 18. Discrepancy 18a. Discrepancy Indication Space ❑ QuantityType ❑ YP El Residue ❑Partial Rejection ❑Full Rejection Manifest Reference Number: 18b. Alternate Facility (or Generator) U.S. EPA ID Number V Q �+- Facility's Phone: w 18c. Signature of Alternate Facility (or Generator) Month Day Year Q Z cn N 19. Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste treatment, disposal, and recycling systems) 0 1. 2. 3. 4. 20. Designated Facility Owner or Operator. Certification of receipt of hazardous materlalS covered by the manifest except as noted in Item 8a Printed,—, yped karne Signature Month Day Year trH r-orm uruu-zz (rev. a-uof rrevious ecmuvns are UUSUiere.