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Please print or type.(Form designed for use on elite(12-pitch)typewriter.) Form Approved.OMB N6,1950-0039 <br /> UNIFORM HAZARDOUS I'-Generator ID Number ~�L4+11��362 2.Page 1 of 3.Emergency Response Phone 4.Manifest Trac' g Number � <br /> WASTE MANIFEST 1 i-800-46&-17601 002184340 <br /> S.tperd,Ll ftdffdail'I�g rets Generator's Site Address('rfdifferent than mailing address) <br /> i�. �17.i.t' <br /> GA 95215 . <br /> Generator's Phone: <br /> 6:3ra/Is r�ryl PFTm yS I EM f INC, U.S.EPA ID Number TXRI O1015093f <br /> z�,- <br /> 7.Transporter 2 Company Name U.S.EPA ID Nu bene <br /> 8.Designated Facility Name and Site Address 'J I't I Y"I;LhhN t�Y j t CI'!:: 1 NC . 14100b 18 U.S.EPA ID Number <br /> i'722 600PER CREEK 96AD <br /> DENT(3N, TX 76208 <br /> 940-483-5-200TXDO77 ,I 337E <br /> Facility's Phone: <br /> 9a. 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,Ip,Number, 10.Containers 11.Total 12.Unit <br /> 13.Waste Codes <br /> HM and Pacidng Group(if any)) No. Type Quantity wt./Vol. <br /> A i.iIL4 WlAb,I I-LHFIM1451 L L IL4�'r'1t1a; iyt_u>b, QM 1j LJ fd2 s I "Ju; <br /> (P-C 1Ly.RQBENZCTR1 LQnRIDE) r 211'J-# <br /> 3 UN1 93 Pia TIT {DIgi ) � I <br /> Z 2. <br /> W <br /> r-7 <br /> 3. <br /> 4. <br /> I <br /> I <br /> — — 4i.-Spee?a�lHandinganstax:4oasandAd&onallnfwnaGon._.�3 . 1 `1427,35 <br /> 24 HR EMERGENCY 800-468--1762I(SAFETY-KLEEN - 94138) <br /> 5f; PUTWD TO USE SUBSEQUENT CARRIERS: 40067, 41030, 82729, 85399, 87585 <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 conform to the terms of the attached EPA Acknowledgment of Consent. <br /> I cert fy 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 quantiVgenera(,or)is.#ue. <br /> Gen or SJOfr�ror s Printed/Typed Name Signature )f Moonnthf (D�a /Year <br /> 16:International Shipmenls f f <br /> Import to U.S. ❑Export from U.S. Pdrt o <br /> 11f entry/exit <br /> Transporter signature(for exports only): Date leaving U.S.: <br /> W 17.Transporter Acknowledgment of Receipt of Materials —, <br /> 12 Transpa br l Printed(Typed Name F -- Signataf" Month1 /Daa)y[r, Year <br /> rf U,fl <br /> Transporter2 Printedlr peo.Name Signature Month Da 'Year <br /> 7TO,- <br /> 18.Discrepancy <br /> Iaa.Discrepancy Indication Space ❑ Quantity ❑T e Residue <br /> YP ❑ ❑Partial Rejection ❑Full Rejection <br /> Manifest Reference Number. <br /> 18b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> J_ <br /> V <br /> Facility's Phone: <br /> QW 18c.Signature of Alternate Facility(or Generator) Month Day Year <br /> Y <br /> 19.Hazardous Waste Report Management Method Codes!i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> LLJ� 1 2 3. 4. <br /> 20.Designated FaciO Owner or dperator.Certi6cAa on of receipt of hazardous materials covered by the manifest ex"as noted in Its 18a <br /> PrintedlTyped Nam!/ / y r/j��j�fj Signnaalu ,f`// Month Day <br /> Yeaa <br /> EPA;Fsou�1� 70(�2(Re`.3 05) Previous edofns are ob�lej. 4 D NATED FACILITY TO GENERATOR <br />