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2 plc' <br /> Please print or type.(Form designed for use on elite(12-pitch)typewriter.) Form Approved.OMB No.2050-0039 <br /> Emergency Res onse Phone 4.M IfOt T1ker <br /> WASTE MANIFEST1.Generator ID Number e 9 <br /> "17-12 E L EUNIFORM HAZARDOUS <br /> 5 Generator's Name and Mailing Address Generator's Site Address(if different than mailing address) <br /> Y <br /> St ockt or. GP 95215-9662 <br /> Generator's Phone: <br /> 6.Transporter1 Company tea a U.S.EPA ID Number <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> 8.Designated Facility Name and Site Address Si�F -r'Y„„t{[.FT:"N SY"TC-MS INC. U:S:E�QJD Number <br /> 3.722 COOPER CFrEI X; R04D <br /> DENT^ TX MR-00 <br /> Facility's Phone: 9414-48 33-5,"1-1110 1 <br /> 9a, 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 Wt.Nol. <br /> rv: ,.iwa._. DM'. D a <br /> t <br /> W ��y❑ <br /> f7t-':p1 't';3ie;Y•'.i►D(aUS 1�}1`�S'FE,501L,10 <br /> L 41 <br /> 3. <br /> 4. <br /> 14.S ecial Handlin Instructions and Additional InformationSK <br /> ra; <br /> ,�^ •y ry� g T;^Qt L'y'fi.t tr'p � . .'e } <br /> 349 1,.1'rR:T[4_3t~. f!'.�f ASF i ;17't'��75-..L!.�Clt�"a.1 .+67 (SW-KT�7"i�'�6�.�N 'At t e,Z <br /> , F'ARIR V.'S t 41078.41.4/1.,81,6813 <br /> 15. GENERATOR'SIOFFEROR'S CERTIFICATION: I hereby declarethat 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 international 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 I am a large quantity generator)or(b)(if I am a small quantity generator)is true. <br /> Generator's/Offeroes Printed/Typed Name Ngnature Month 04y.- Year <br /> /�j <br /> -J 16.International"Shipments <br /> ❑Import to U.S. ❑Export from U.S. Port of entry/exit: <br /> Z <br /> Transporter signature for exports only): Date lea ving U.S.: <br /> W 17.TransporterAcknowledgmentofReceipt ofMaterialsY, <br /> Transporter 1 Printed/Typed Name ignature �, Month Day Year <br /> QTranspo ter 2 Printed/Typed Name igrthroP w" Month Day Year <br /> H <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space ❑ Quantity ❑Type ❑Residue ❑Partial Rejection ❑Full Rejection <br /> Manifest Reference Number: <br /> 18b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> J_ <br /> V <br /> Facility's Phone: <br /> W 18c.Signature of Alternate Facility(or Generator) Month Day Year <br /> Q <br /> Z <br /> N19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> � <br /> 1. 2. 3. 4. <br /> 20.Designated Facility Owner or Operator.Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a <br /> PrintedlTyped Name Signature Month Day Year <br /> EP�F r 870 22,( gy r- eGENERATOR'S INITIAL COPY <br />