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Please print or type.(Form designed for use on elite(12-pitch)typewriter.) Form Approved.OMB No.2050-0039 UNIFORM HAZARDOUS 1 1 Generator ID Number 2.Page 1 of 3.Emergency Response Phone 4.Manifest Tracking Number YJASTEMANIFEST � CC� ( 13C� }�1?'L�L��'�i�� 018486180 JJK 5.Generator's Nam Mailin" f ress Generator's Site Address(if different than mailing address) t--IZLM't `(LC-6 ir- u'. -r9(,'w-To-j Generator's Phonct_. C-/\lzw ASM Y �-k o Q—Transporter 1 Company Name U.S.EPA ID Number LI 7.Transporter 2 Company Name U.S.EPA ID Number 8 Designated Facility Name and Sit.Address U.S.EPA ID Numbw Fadity'sPhone:UL- Ct 1 .r �-� t GZ• �f IC-ADD?kWqcjt9 ga, 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 0.C cntaine s 11.Total 12,Unit 19.waste Codes HNo HM and Packing Group(if any)) , Type Quantity V-VVoi, (Of Ly E"krrL-LLI 4. JUN 2 4 2019 14. eclat Handling ins!rucNons and Addilicnal lnfomialion HEAL-1-H 1) t UG S-�ZZ DEPARTIMFNT 2)ta6-Lz —'�s3 i I - lit-cfuzz 15. GENERATOR'SIOFFEROR'S CEPTIFICATIOiI: 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!piacarded,and are in all respects in proper condition for transport according to apoicable international and national governmental regulations.If export shipment and I am the Primary Exporter,I cerfiy that the contents of this consignment conform to the terms of the attached EPAAcknoMedgment of Consent. I cert-'y that the waste minimization statement Identified in 40 CFR 262.27(3)(if I am a large quantity generator)or(b)(dt am a small quantity generator)is true. Generatoes/Offerces PrintedlTyped Name Signature �. Month Day Year C -116.Intemaiional Shipments p. ❑Import to U.S. ❑Export from U.S. Port of entryleAt z Transporter signature(for exports only): Date leaving U.S.: �= 17.TransporterAcknowledgment of Receipt of Materials �w ftonth Day Year Transporter 1 Pri yped Name Q Transporter 2 P tedlTyped NamSiynaptn hfonih Day Year ' l- 18.Discrepancy r—� 18a.Discrepancy Indication Space ElOwlity ❑Type ❑Residue ❑Partial Rejection ❑Full Rejection Manifest Reference Number. 18b.Alternate Facility(or Generator) U.S.EPA ID Number __r u- Facility's Phone: tilon:h Day f 0 18c.Slgrature of Alternate Facility(or Generator) ear Q 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste lreatmant,disposal,and recycling sys!ems) uJ 2. 3. 4. 20.Designated Facility Owner or Operator,Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a PrintedlTyped Name Signature Month Day Year EPAFont ^�IRev.3-05) Previous editions areob,olete. LidIGNATED FACM-i i , I La,TINATIGf, i,'%TE (IF i=:cVIJIRED)