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Please print or type. (Form designed for use on elite (12 -pitch) typewriter.) Form Approved OMB No 2050-0039 <br />EPA Form 810U -2Z (Kev. J-Ut)) Previous eanions are oosoiete. (itNtKAIUK'b IN] I tAL L;UFT <br />UNIFORM HAZARDOUS <br />1. Generator ID Number <br />2 P <br />y Response Phone <br />4. Manifest Tracking Number <br />MANIFEST <br />1 <br />.—A4- <br />FLEWASTE <br />5.— <br />Generators Name and Mailing Address Generator's Site Address (if different than mailing address) <br />erla Ity Cheese <br />14a53 6 AiPport ZY <br />Generators Phone: <br />6. Transporter I.Company Farris- <br />U.S. EPA ID Number <br />FN SYSTM INC <br />7. Transporter 2 Company Name <br />U.S. EPA ID Number <br />CLEAN HARBORS r--'N1111R0NMF.NTAL '-.,VC INC. <br />8. Designated Facility Name and Site Address CLEAN HARBORS ENV R"ENIAL. SMI GEC, 1 t -j U S. EPA ID Number <br />2P47 S HrfRHWAY 71 <br />1`0 MBAI -1. NF,- 691-14t, <br />08-236 -401 F <br />Facility's Phone: <br />9a <br />9b. U S. DOT Description (including Proper Shipping Name, Hazard Class, ID Number, <br />10. Containers <br />11. Total <br />12. Unit <br />Waste Codes <br />No. <br />Type <br />HM <br />and Packing Group (if any))13. <br />Quantity <br />Wt.Nol. <br />1. <br />PAM, s, PG 11 <br />"OK <br />0 <br />000 <br />DWI:, <br />Z <br />1JJ <br />UN3JU7 ENVIRONMENTALLY HAZARDOUS <br />431 <br />IWID N.U.S., <br />(PYRETHRIN��), 91 k, III <br />3. <br />4. <br />14. Special Handling Instructions and Additional Information <br />DBO i ICA <br />LPG# I ER64171 <br />f.t aH F4 -Y i -),'71K TY--Tr, I• p �1, <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 EPA Acknowledgment of Consent. <br />I certify that the waste minimization statement identified in 40 CFR 262.27(a) (if 1 am a large quanbty generator) or (b) (if I am a small quantity generator) is true. <br />Generators/Offerors Printed(Typed Name Signature <br />on Day Year <br />16. International Shipments <br />0 Import to U.S El Export from U.S. Pon of entryleml: <br />Transporter signature (for exports only): Date leaving U.S.: <br />IX <br />uJ <br />17. Transporter Acknowledgment of Receipt of Materials <br />0: <br />Transporter I PhntedfTyWd Name Signature <br />on Day Year <br />0 <br />z <br />Transporter 2 Printedrryped Name Signature <br />month Day Year <br />9 <br />I <br />I 1 1 <br />:_ <br />- <br />Discrepancy <br />I18. <br />18a Discrepancy Indication Space ❑ Quantity 0 Type ❑ Residue <br />❑ Partial Rejection <br />❑ Full Rejection <br />Manifest Reference Number: <br />18b. Alternate Facility (or Generator) <br />U.S. EPA ID Number <br />Facility's Phone: <br />w18c. <br />Signature Of Alternate Facility (or Generator) <br />Month Day Year <br />19. Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste treatment, disposal, and recycling systems) <br />0 LLJ <br />1 <br />2. <br />1 <br />1 <br />1 <br />4. <br />1 <br />20. Designated Facility Owner of Operator. Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a <br />Prinled(fyped Name Signature <br />Month Day Year <br />EPA Form 810U -2Z (Kev. J-Ut)) Previous eanions are oosoiete. (itNtKAIUK'b IN] I tAL L;UFT <br />