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r,Nw•cupy 10: Al"W PO.8©x ntiU 61tcCr04l9txtcor C:e•�1TrF,1�-�OdgO <br /> WItW 10( w <br /> Please print orM Form Approved.OMB tl('77;J1iO3D <br /> .(F fined for use on elile 112-ndch)"Witter) <br /> UNIFO'' {{(�. - US tsl <br /> -Ganerabr tD NumO t 2 Page 1 0l 3.Emergency Reonse Ptrore !.Maniksl Tracking Number <br /> WA EM" ST y:,, .JA:1�i �0 <br /> 48 JJK I <br /> Ge'°'e s Name arse M2iFm AddBss Gwre2 or's Srte Add ess fr Tnerem tnan rtsn6ng address) <br /> - U 5 EPA ID Number /�., <br /> � an�,r ner•C�mjany Name �y <br /> t,.lsir.ei3dsn elf- <br /> a�spsier Z Company Name U.S.EPA ID Number <br /> a Des;gnaled F-W+tame and Ste Address US EPA ID Number <br /> F—',.Y$Phone: . <br /> 9" 9b.18 DOT Desmpbon(including Proper Sh ppmg Name,Harard Class,ID Number 10,Containers 11 Total 12'Uro, 13.Waste codes <br /> HM ana Padang G—o(if aryl) No. TypF 0uo,1 ly s`II i lel l^l <br /> Cr <br /> 1� <br /> O V <br /> a <br /> W <br /> W L <br /> n � <br /> C <br /> b <br /> J <br /> 14 Spec al Handling Insbucuons and Additional Infonnation <br /> (D <br /> 15 GENERATOR'S/OFFEROR'S CERTIFICATION:I hereby declare that the contents of this consigment are fully and accurately descrbed above by the proper shippng name,and are classified.packaged, V • <br /> Q., marked and labeledyplacarded,and are in all respects in proper condiben 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 /> 1 certifyIhdt the waste minimization statement Identified In 40 CFR 262 27 a if I am a large quantity generator)or (d I am a small uarti enmior is true <br /> - O( 9 V N9 O V h9 ) <br /> p• Gerwralor's'Offeror's Pnnted/Typeo Name Signakrre tdnnth Day Year <br /> (D 16.International Shipments <br /> Q. ❑Import to LLS, ❑Export from U.S. Pod of entryleut <br /> Transporter wpalure(for exports only): Date leaving U.S.. <br /> 17.Transporter Acknowledgment of Receipt of Materials <br /> Transpoder 1 Prinled(Typed Name Signature _ MontID <br /> `C r <br /> n Transporter 2 Prinled/Typed Name Signature Mon <br /> O <br /> � 18.Discrepancy tr�,, FF��1 18a.Discrepancy Indu;atiun Space Quantity u Type Residue L 1 Parual Rejection <br /> Manifest Reference Number. <br /> U.S EPA ID Number <br /> O_ '_ 18b.Alternate Facility(or Generar) <br /> O <br /> C Fa alifyra Phone: Mcnlh Day Year <br /> Fa <br /> 18c.Signature OfMem <br /> Facility for Generator) <br /> CDO <br /> Managamenl Methal Codes(i.e.,codes for hazardous waste Vealnlant,disposal,and recycling systems) ""04. <br /> � 1 18.Havardou Waste Rwoft 3 l <br /> 2. <br /> D 1. <br /> C /] <br /> cQ <br /> 20.DadynsW WHY(oaf o!pperatpr.Ce dficatbn of receipt of hazanlOus mater cuts covered by the manifest accept as noted in Itmn 18a Month Day `leap <br /> � Signature r.er <br /> .-rN�fMI a <br /> cn GENERATOR'S INITIAL CO <br /> N Folli (Rey.3"05) ReYlous editions are obsolete. <br /> CD `O <br /> F. <br /> w <br />