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i r Please print or type.(Form designed for use on elite(12-pitch)typewriter.) Form Approved.OMB No.2050-0039 UNIFORM HAZARDOUS 1.Generator ID Number 2.Page 1 of 3.Emergency Response Phone 4.Manifest Tracking Number WASTE MANIFEST >4iU 3 16.66cf 3 9 JJK 5,Generator's Name and Mailing Address Generator's Site Address(if different than mailing address) Generator's Phone: 6.Transporter 1 Company Name U.S.EPA ID Number 7.Transporter 2 Company Name U.S.EPA ID Number B.Designated Facility Name and Site Address U.S.EPA ID Number v ra!°ttty f'uitfa�'j.T+3iMA�.k id'iii. :+Ji fi�yj3(113i. Facility's Phone: ga. 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit 13.Waste Codes HM and Packing Group(if any)) No. Type Quantity WtNol. 1. 0 i O 71 i 1 Z 2. ± ! C) Il 3. i 4. I i 14.Special Handling Instructions and Additional Information ifil'.04:c fF 00` 15. GENERATOR'SIOFFEROR'S CERTIFICATION: 1 hereby declare that the contents of this consignment are fully and accurately described above by the proper shipping name,and are classified,packaged, 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 Exporter,I certify that the contents of this consignment conform to the terms of the attached EPAAcknowledgment of Consent. I certify that the waste minimization statement identified in 40 CFR 262.27(a)(if I am a large quantity generator)or(b)(if I am a small quantity generator)is true. Generator's/Offerors Pdntedffyped Name Signature Month Day Year f J 16.International Shipments l'- ❑Import to U.S. ❑Export from U.S. Port of entrylex t Z Transporter signature(for exports only): Date leaving U.S.: W 17.Transporternowgmen Acknowledgment of Receipt of Materials l"- Transporter 1 Printed/Typed Name Signature Month Day Year yf l Z Transporter 2 Printed/Typed Name Signature Month Day Year + W I F- 18.Discrepancy 18a.Discrepancy Indication Space ❑ Quantity ❑Type ❑Residuej j ❑Partial Rejection El Rejection I Manifest Reference Number: F i 8b.Alternate Facility(or Generator) U.S.EPA ID Number J U tai Facility's Phone: w 18c.Signature of Alternate Facility(or Generator) Month Day Year a Z 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) UJ 1. 2. 3. 4. 20.Designated Facility Owner or Operator.Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a Printed/Typed Name Signature Month Day Year EPA Form00- (Rev.3-05) Previous editions are obsolete. GENERATOR'S INITIAL COPY a- 4 � �