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Please print or tvoe. (Form desianad for use on elita (19.nitch) 1—awrilor 1 <br />ri-A rornt oruu-tt (Kev j -u5) Previous eamons are obsolete. GENERATOR'S INITIAL COPY <br />roan Approved. UMb No. 40-UU3� <br />anifest Tracking NumWr <br />UNIFORM HAZARDOUS 1. Gcnor-d or ID Number 2 Pago 1 of 3 Emergency R=010243Uq'- <br />WASTE MANIFEST FLE <br />5. Generators Name and Moping Address Grneralor's Site Address Qf dlflerenl than mailing address) <br />Gnnuralors Phone: law <br />6 1 ransporler 1 Company Name U 5, EPA ID Number <br />ft (SV) -``nn 7 CAI ' <br />7 1 ransporler 2 Company Name U.S. FPA ID Numbor <br />8. Designated Facility Name and Site Address LLS LPA ID Number <br />i <br />!s <br />Faclit 's Phone: <br />ga, <br />9b U.S. DOT Description (Including Proper Shipping Name, Hazard Class, ID Number. <br />10- Containers <br />11. Total <br />1, and <br />HM <br />and Paddng Group (ff any)) <br />Quantity <br />Wt Nnt <br />13. Waste Codes <br />No, <br />Type <br />-- <br />w <br />: <br />W� <br />cis R R 11; Y. .tjwwl%- "iI.Ad (F(x f'i S' <br />Ff <br />I i <br />/ <br />I <br />t <br />3- <br />- I - ; <br />I <br />I <br />4. <br />f , <br />i <br />14 Spenal Handling InnsyWydiion�and Additional Informationpow INDr, <br />,s <br />yr-e-rF4mil'AY , . f A- :5 CST <br />15. GENERATOR'SIOFFEROR'S CERTIFICATION: I hemby dodare that the contents nt this caisignment are fully and accurately doscibed above by the proper shipping name, and are classified, packagm. <br />marked and labeledlplacerdod, and are in all respects in propos 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 ideritiriod in 40 CFR 26227(a) (if I am a large quantity generator) or (b) (if I am a small quantity generator) is true. <br />G.eincrator'siollfaroes PrintediTyped Nanlr, ignalura Month Day Year <br />J <br />16. Intem:atrnnal Shipments �I 1 - <br />L.- 1 Import to 11 5 <br />Z <br />LJ txprnt from U.S: Port of entry/wat _ <br />— <br />Transporter signature for exports only) Date leave U.S.: <br />W <br />17, Transporter Acknowledgment of Receipt of Materials <br />Transporter 1 PnntedfTypeo NameMonth Day YOai <br />CL <br />Cn <br />1atsporter2 PftCypedNine tgnsturt: -- Monti Day Year <br />18. Discrepancy <br />18a Disacpancy Indication Space Quantity ❑ Type ❑ Residue ❑ Partial Rejection ❑ Full Rejecticc <br />Manifest Reference Number <br />18b. Alternate Facility (or Generator) U.S- EPA ID Number <br />U <br />li <br />Facility's Phone <br />18c. Sionature of Alternate Facility (or Generator) Month Day yeor <br />Q <br />z <br />y1.9 <br />Hazardous Waste Report Management Mcltutd Codes (.e., codes for hazardous waste treatment, disposal, and recycling systems) <br />p <br />1. <br />2 <br />3. <br />a. <br />20 Designated Facility Owner or Operator. Certification of receipt of hazardous materials covered by the manifest except as noted in Ilium iiia <br />Pnnted/Typed Name 5ignalu a MOrlgl Day Year <br />ri-A rornt oruu-tt (Kev j -u5) Previous eamons are obsolete. GENERATOR'S INITIAL COPY <br />