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Please print or type.(Form designed for use on elite(12-pitch)typewriter.) Form Approved.OMB No.2050-0039 <br /> 1.Generator ID <br /> Number 2.Page 1 of 3.Empr�ency Response.P11[l 4.M T c u r <br /> UNIFORM HAZARDOUS (; l.V7Qf1'�'E!F! ",�N 3 J_.'1j k"� 46 1 E�itl 00 �g 4 85 F E <br /> ' WASTE MANIFEST <br /> 5.Generator's Name and Mailing Address Generators Site Address('d different than mailing address) <br /> j7ROGRV? T-' R.P j 1. <br /> 6.514.0 Fal.i�`i tr+ kil <br /> Generators Phone: <br /> Transporter ompanX ame U.S.EPA ID Number <br /> Ci Flt c'.TV-rt..f_FN ;`ra:;TE:�i q TNC� rXA4:'+Pta_ii► f xiB <br /> 7 Transporter 2 Company Name U.S EPA ID Number <br /> 8.Designated Facility Name and Site Addressv_ c• r, , h U.�YPdD Number <br /> VCTrZq <br /> 1'X 711'� �A�; <br /> 7vz <br /> Facility's Phone: <br /> ga 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total Wt Unit 13.Waste Codes <br /> HM and Packing Group(if any)) No. Type Quantity .Nol. <br /> ?:fi,tt44I.LFD WI.T4_fVJKA_=.... <br /> om <br /> o <br /> 4:4 9Tt-) <br /> T IL <br /> �F1' W <br /> 2 !�!tlty +C'c;A FirlI+1FZI1�Iti WASTE. �(A. if) OmL' ;i"t' l2lJ <br /> al[r, CORN COB 148SPREIPNTI, <br /> 4. <br /> 14.Special Handling Instructions and Additional Information <br /> SK qiUW4#-k <br /> CA HR E Y+lF frl ii INCY C-600-468-2760 <br /> 5K P;I!'rT'0 'ro IJ:?nt Pgfit:f,?itE.:ir <br /> 15. GENERATOR'SIOFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by the proper shipping name,and are classified,packaged, <br /> marked and labeled/placarded,and are in all respects in proper 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 of to the to ms of the attached EP knowledgment of Consent. <br /> I certify that the w tem 'mization, ement dentifin 40 F 262 (a)(if a large q tity generator)or(b) 1 a a small uantity ge tor)is We s <br /> enerato erfors nt ype a Wa re on ay eaf- <br /> ! ( ` f <br /> —J 16.IntemaWnal Ship is <br /> I- Import to U.S. ❑Export from U.S Port of entryte : <br /> Z <br /> Transporter signature Vo(exports oni Date leaving U.S.: <br /> Wrr 17.Transporter Acknowledgment of Receipt of Materials <br /> Transporter 1 Pnnted/T Name / ,. gna ure r" � .� , ont ay ear <br /> CL <br /> i Transpor nt TTyped Name Signature on ay e <br /> rtear <br /> Q <br /> H <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space ❑ Quantity ❑Type ❑Residue ❑Partial Rejection ❑Full Rejection <br /> Manifest Reference Number: <br /> 18b.Alternate Facility(or Generator) U.S EPA ID Number <br /> J_ <br /> V <br /> Q <br /> LL <br /> Facility's Phone. <br /> 18c.Signature of Alternate Facility(or Generator) Month Day Year <br /> Q <br /> Z <br /> 019.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> W1 2, 3. 4. <br /> 20.Designated Facility Owner or Operator Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a <br /> Printed/Typed Name Signature Morth Day Year <br /> EFjq �Ii 22( �'pawousp ttl�+�8r414060%941 �j.�� cj vj� rte. GENERATOR'S INITIAL COPY <br />