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Form Approved. CMB No. 2050-0039 <br />r Cam <br />UNIFORM HAZARDOUS <br />r — <br />1 Generator 10 Number <br />'; i� �t�ry'/ ;jEt�6 <br />j1.Pj1o1j1jE7 <br />se <br />- t: • i � bit <br />4. Manliest Track)pg <br />0 f'� ` <br />Number <br />1,04 e J[ (� <br />1 � 41,04 <br />WASTE MANIFEST <br />t/ f� a7 <br />5. Generawes Name and �a Mdrm GeneraWs Site Address (A different Nan mailing address) <br />,,;lf_ (; f311NIA MIX I_ NFS INC <br />4�� 3105 r <br />fiTCtC Klx-ON fAE95?i36�Oc45 <br />`}-4 ' ' 3554 <br />Generaars Phone: <br />U.S. EPA 10 Number � <br />6 T`,r 1fC "" SVS -r ms' INC. r r :, au, Ivi0509.-, j <br />'. � P <br />7 Transporter 2 Company Name U.S. EPA 10 Number <br />8, Designated Facility Name and Site Address ; 3(WF- TM—KLr'-XN SYS rFMS, INC. j ha 1 U S. EPA 10 Number <br />1722 COMER CREEK RO <br />n�-rON, rx ; -�.-�.,s <br />T X D07 7603371 <br />�1lydl-483-.� <br />Facd 9 Ptuone: <br />9b. U, S. DOT Desc ipdM (kititdrq Proper Shipping Name, Hazard Class. ID Number, <br />10. Containers <br />1 t 'rtal <br />12 U n't <br />13. Waste Codes <br />rro. <br />Type <br />HM <br />and Pacl irg Group (t arty)) <br />aroty <br />vt_ 1a <br />X <br />I - Pa WASTt: FLAMMMLE L 1011105, N.G.S. <br />o <br />(A—CHLOROHENZOTRIFLUORIUE) <br />, <br />3 I JN 1993 PG t I t (0" 1) <br />_ <br />1 <br />Z <br />2 <br />w <br />c7 <br />3. <br />4 <br />14. Special Handling Instructions and AWAmal Intam tow SK SH I PiF MI75809 7 11.' 1 - 51 <br />t)ERC3#0128 <br />24 HR EMERGENCY 41-800-468-1760 (SAFETY—KLEEN — 9408) <br />TO USE 5118SEIIIJENT CARR IER9141078 4t471 St 681 02739 3':399 <br />SK f)(JTH' D ed, <br />CERTIFICATION: I he declare Nat the contents of tt+it consigrKnMd ale fiiy and ecaratety described! adore by the doper shropng name, and are classified, packaged, <br />Primary <br />15 GENERATOMMIFFEROWS <br />adlrm0onal and nattonaf governmerlal regulations. If export sh pment and I am Ne <br />marked and IabeleNplawrded, and are ut a1 respects in proper corlditldn for transport according to eppleabfe • <br />Exporter, I certify that the contents of Nis consignment conform to the terms of dhe attached EPA Acknowledge aril of ConsenL <br />statement denofed in 40 CFR 262 27(a) (if 13m a large quantity generator) or (b) (if l am a smal quantity generator) s :rue <br />I car* tt at this waste minimQatieon <br />Signature NWth Cay Year <br />GenerotdfslORerors Printed/Typed Name <br />16. International Shipment <br />Import to U S. ❑ ❑Export horn u s. Port a entryfmdC <br />F <br />Transporter stgunatm (for exports duty) Data eavng U.S.: <br />LLJ <br />17. Transporter AdoavAedgment of Receipt at Matenals ' <br />s Month pay <br />Transporter 1 Pnrte&Typed Name Signature <br />N.... <br />SgnaNre Month Day Year <br />2 <br />Transporter 2 Pririid yped Name <br />4 <br />Z <br />F- <br />1?. G-screpanq <br />!?a D,sr-.repancy InCiration Space ❑ Ouancry ❑Type L_.1 Residue auy Refsttron ❑ Ful Rejection <br />Manifest Reference Number. <br />US EPA 10 Number <br />1 Pb L!errate FacA;ty for Generator) <br />U <br />Facility's Phone: Mordh Day Year <br />w 18e. Signature of Aitemate Facility (or Generator) <br />Q <br />Z <br />y19. Hazardan Waste Repot Management Meead Codes (Le.. codes for hazardous waste treatment. disposal. and recycling systems) <br />4 <br />ttl <br />1 2. 3. <br />0 <br />20. Designated Facility Owner or Operator Certification of receipt of hazardous materials covered by the man" except as noted in Will 18a -rn <br />NntediTyped Name Signature <br />GENERATOR'S INITIAL COPY <br />EF?NFR pq-p,(Rey. 3-05) Preytous eatbons are oasotete. <br />