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Please print or type. (Form desgiod for use on elite (12•pitdi) typowrilec) <br />UNIFORMHAZARDOUS 1. Generale, ID Number <br />WASTE MANIFEST &W -OM 71 tf i <br />5. Generators Name and M&Iling Address <br />06 S. M Dot" Amuse, ;E) �e;-v`�rfli r��l�n�:.cetrt <br />Coneralor's Phone: y4 <br />5 Transporter i Company Name <br />;�. P_c,t; t;:a ,,cai ifarrispwt RIG• (Si) <br />l.x <br />FaalilI's Phone: <br />ga, 9b. U.S. DOT Description (Including Proper Shipping Name, Ha zaid Class. ID Number, <br />HM and Packing Group (d any)) <br />1' f:rtri t�f.c..41�4tr.i1'1.:, t'rr3>P(<<:i+r�tti (f1$'ylditr'.� <br />2. +v75 rR ICI I't �d�l/a/iSCL11r•a <br />17;r.f'4t• '44 AM 01 C*(`'�•f <br />Form Approved. ON1i3 No. 2050-0039 <br />y Rowse Phone 4. ManifestTracking Numbor <br />24 Q$:.. FLE <br />Number <br />5' a <br />10. Containers <br />11. Total <br />Quantity <br />1x, Unit <br />Wt NOL <br />13. Waste Codes <br />Na, <br />Type <br />163. Discrepancy Indication Space <br />❑ Ouantlty <br />❑Type <br />❑Residue <br />❑Partial Rejection <br />❑Full Rejection <br />`I <br />1 p;4, al Handling Instructions and Additional Information <br />15. GENERATOR'SIOFFEROR'S CERTIFICATION: I hereby declare that the contents of this emisignment are fully and accurately doscribed above by the proper shipping nams, and are classified, packaged, <br />marked and labeled/plaoarded, and are in all respects In proper condition for transport according to applicable international and national govoinmental regula5ons. If expert shipment and I am the Pdmary <br />&.porter, I certify that the contents of Iltls consignment conform to the terms of the attached EPAAcknowledgmenl of Consent - <br />certify that the waste minimization statement identifiud in 40 CFR 26227(a) (if I am a largo quantity generator) or (b) (if I am a small quantity generator) is tore. <br />tor'si0genlenn yped Name ignaturo on a ear <br />Y <br />16. Intemabonal Shipments , <br />❑Import to U.5 ❑Expert from U.S: Pori of entrylendt _ <br />Transporter signature (for exports only) Date leaving U.S.: <br />17. TranWorterAckrowtedgment of Rewipt of Materials <br />nsportw 1 PnntEF yped Name Signature rMonth Day YOar <br />19, HoWdoua Wester Report Management Method t6dgj (f.i3_ codes for hazardquswaste lraalmenl, <br />20.DealgnAtedradilily,6merofOpema C.erdf41116nofrec*idhazardws.materials covered bythe <br />Printed/Typed Name <br />Previous editions are obsolete, GENERATOR'S INITIAL COPY <br />18, 01screpancy <br />163. Discrepancy Indication Space <br />❑ Ouantlty <br />❑Type <br />❑Residue <br />❑Partial Rejection <br />❑Full Rejection <br />19, HoWdoua Wester Report Management Method t6dgj (f.i3_ codes for hazardquswaste lraalmenl, <br />20.DealgnAtedradilily,6merofOpema C.erdf41116nofrec*idhazardws.materials covered bythe <br />Printed/Typed Name <br />Previous editions are obsolete, GENERATOR'S INITIAL COPY <br />