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Please print or type. (Form designed for use on elite (12-nitchl Ivnewrifer 1 <br />��r c• �u� cumvi s are wsuieie. GENERATOR'S INITIAL COPY <br />-I <br />UNIFORM HAZARDOUS <br />I1 11- _ <br />1 Generator ID Number <br />2. Page 1 of <br />3 Emergency Response Phone <br />corm Approvi UMb N0. ZUbU-UU39 <br />4. hlanffest Tracking Number <br />WASTE MANIFEST <br />� �[ <br />Jill <br />f� <br />5. Generators Name and Mailing Address Generators Site Address (if different than mailing address) <br />Generator's Phone: <br />6. Transporter 1 Company Name U.S. EPA ID Number <br />1, Transporter 2 Company Name U.S. EPA ID Number <br />8. Designated Facility Name and Site Address U.S. EPA ID Number <br />Facili '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 />12. Unit <br />HM <br />and Packing Group (i( any)) <br />Quantity <br />Wt.iVol. <br />13 waste Codes <br />No. <br />Type <br />L <br />O <br />z <br />2. <br />W <br />C9 <br />3. <br />4. <br />14. Special Handling Instructions and Additional Information <br />t3tr'11o10' t'T?% <br />AEs`31 n7 {J1 .-i�1d6;7 M5T•E iiiV it rr fk <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 labelediplacarded, 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 conform to the terms of the attached EPAAckno vledgment of Consent. <br />I certify that the waste minimization statement identified in 40 CFR 26227(a) (if I am a large quantity generator) or (b) (if I a a small quantity genera is true. <br />GeneratorsfOfferors Printed/Typed Name S gnatur / Month Day Year <br />d S - <br />-J <br />ZImport <br />16. International Shipments ❑ <br />to U.S. ❑ Exoort from U.S. Port of entry!l <br />— <br />Transporter signature (for exports only): Date leaving U.S.: <br />W <br />17. Transporter Acknowledgment of Receipt of Materials <br />OTransporter <br />1 Printed. Typed Name Signature MOh� Yom_ <br />n <br />rn <br />t.. �' . <br />'- <br />aQ <br />Transporter 2 PrintedlTyped Name Signature Month Day Year <br />rr <br />F- <br />18. Discrepancy <br />18a. Discrepancy Indication Space ❑ QuantityT1 e <br />❑ E] Residue ❑Partial Rejection ❑ Full Rejection <br />Manifest Reference Number. <br />Ill Alternate Facility (or Generator) <br />U.S. EPA ID Number <br />U <br />Facility's Phone: <br />H18c. <br />Signature of Alternate Facility (or Generator) Month Day Year <br />Q <br />Z <br />lug <br />19. Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste treatment, disposal, and recycling systems) <br />UJI C3 <br />1' <br />2. <br />3. <br />4. <br />20. Designated Facility Owner or Operator: Certification of receipt of hazardous materials covered by the man'rfest except as noted in Item 18a <br />PrintediIypedName Signature Month Day Year <br />Foe <br />F,..,,, A7111)Inro..,, v nc: n...:.._ _ <br />��r c• �u� cumvi s are wsuieie. GENERATOR'S INITIAL COPY <br />