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-r._18 b- Q1 I. <br /> Please print or type.(Form designed for use on elite(12-pitch)typewriter.) Form ApprOV6d,OMB N0.2050-0039 <br /> UNIFORM HAZAROOU5 1.Generator ID Number f'1Aj,fh17jQi.,j.4.4w;r 14 2.Page 1 of 3.Emergency Response Phone 4.Manifest Tracking{Number q y �FS <br /> WASTE MANIFEST 7 'i--F1Git3--+}r;,E!- 1 � ,k� ®�2 18 4 3 4 .1. SKS <br /> a� Ma�ip�A,gress�21,,..�l�t}N_-1: Gen (s Site Address(if ciiRerent than mailing address) <br /> 1 11 <br /> 410A C FRESN"'I OWE 1 .171 ii LiN.10N `:_:Y <br /> C(4 t35E'Vr 1411_`3 W_'!. LDL-300: <br /> c.'AOri• fpf.{;i.. E77,xC;' l`,TLI(:1<I%)N CA 1-45L'.04 <br /> Generators Phone: <br /> 6z �.7sR4r�erl..Cpr4P¢�Yh�me;,`.:..1 -i.7�1�r 1.1+iL.. U.S.EPA ID Number T X kkrV„IIdl71:)('i'3.'r4� <br /> 7.Transporter Company Name U.S.EPA ID Number <br /> 8.Designated Facility Name and Site Address `r c i -h... .t'- ;a 4 h i .P);iy ..Fdi,. 49k?f?i..I It U.S.EPA IO Number <br /> r;Li77i'.:1? t;F(ES_;t C 7far1 <br /> DENTTIN, TY. 76LOER. <br /> i'i;0iN716033171 <br /> Facility's Phone: <br /> 9, 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class.ID Number, 10.Containers 11.Total 12,Unit <br /> HM and Packing Group(if any)) No. Type Quantity Wt.IVOI. 13.Waste Codes <br /> 1 Alt IN HU •.f, -r.:. +.i !. ,15 ie.r i. 11. .., r.J . )a 11+x, -.::s I-Iti I,.i <br /> +7�¢:1]!'1ftdl-_idT (llx;it iJ I1..Y (-y111J1 <br /> Z Z. <br /> w <br /> (7 <br /> 3. <br /> 4. <br /> 14.Special Handling Instructions and Additional Information .. ; .1 u:,. .5w 7 77,1 F- <br /> „4 Hi? EMER;3E:NCY ,-.ylp11;...68 1.:% 0(SAFE':TY--KL.'*-N -- 5A 138 j <br /> SK 1UTHa1a W USE7 ti!)1\ t1'GiUE'Pd3 CAPRTFRSa 400 1. - <br /> 413�;u, e tr <br /> '."r2`•3e Ii3':35, P?riFl`, <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 claseii packaged, <br /> marked and Iatmed/placended,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 tartly 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 identified in 40 CFR 262.27(a)(If I am a large quantity generator)or(b)(if I am a small quantity generator)is We. <br /> GeneratorslO6emes Pdntedfl'yped Name Signature Month: Day Year <br /> j 16.Intemaeonal Shipments <br /> i- ❑Import to U.S. ❑Export from u.6. Pad of entrylexit: <br /> Transporter signature(for exports only): Date leaving U.S.: <br /> w 17.TrensporterAclmowledgment of Receipt of Materials <br /> Transporter i PrintddfTyped Name - Signature ,y Mono Day Year <br /> O i <br /> w <br /> Q Transporter PrintedlTyped Name SignatureMonth Day Year <br /> K <br /> F <br /> 18.Discrepancy <br /> life.Discrepancy Indication Space ❑ Quantity ❑Type ❑Residue ❑Partial Rejection ❑Full Rejection <br /> Manifest Reference Number'. <br /> 186.Alternate Facility lar Generator) U,S.EPA ID Number <br /> J <br /> E3 <br /> ra+. Facility's Phone: <br /> w 18c.Signature of Alternate Facility(or Generator) Month Day Year <br /> Q <br /> Z <br /> v0-i 19.Hazardous Waste Report Management Method Codes(i.e.,cades for hazardous waste treatment,disposal,and recycling systems) <br /> G t. 2. 3. 4, <br /> 1 20.Designated Facility Owner or Operator.Certification of receipt of hazardous materials covered by the manifest except as noted in Item 188 <br /> Printed/Typed Name Signature Month Day Year <br /> FLPQ orr 4171-12(Ray.3-05) Previous adlogns are obsolete. GENERATOR'S INITIAL COPY <br />