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• Form Approved.OMB No.2050-0039 <br /> 4. a.,inifest Tracking Number <br /> n <br /> use on elite(12 pitch)typewriter.) EmergencyPhone <br /> ,2,Page I of', <br /> )lease print ijr type.(Form designed for N, <br /> Generator ID Numbe,1, <br /> UNIFORM HAZARDOUS address) <br /> WASTE MANIFEST Generator's Site Address(it different than <br /> 5.Generator's Name and M,8 <br /> (,A U.S.EPA ID NuTber <br /> Generator's Phone: ......... umber <br /> 6.Transporter Al- <br /> Go Company Name —U�—SE—PA—I D <br /> 7.Transporter 2 Company Name U.S.EPA 10 Number <br /> 8Designated Facility aity Name and Site Address <br /> , <br /> - 0 <br /> k p <br /> J—Iti r�yqNnl GA <br /> 12.Unit 13,Waste Codes <br /> M 10.Containers Total <br /> FacifiYs Phone. N".).7 4' 1�� ,Hazard Class,10 Number, No. Type Quantity wt.Nol. <br /> 9b.U.S.DOT Description(including Proper Shipping Nall <br /> 9a. <br /> HM and Packing Group(if any <br /> .A; 'k 91 1 <br /> 'y <br /> 0 1�',GRA lriAi,%R <br /> OC <br /> 2. <br /> Ul <br /> 3. <br /> 4. <br /> )" <br /> 14.Specitall Handling Instructions and AdditiOrM Information <br /> qI <br /> ' <br /> 0 <br /> 0)" <br /> 0)" <br /> packaged, <br /> PC4AI -------- bvth Proper shipping name,a are classified, <br /> -----,nt are fully and accurate) described abov regulations.it export shipment and I am the Primary <br /> ------�-ntents of this consignment <br /> /OFFER R'S CERTIFICATION. I hereby declare that the co I to applicable international a national governmental qu <br /> 15. GENERAIVIK condition for transport according nt of Consent. <br /> marked and labelediplacarded,and are in all respects in proper( attached EPAAcknowledgment quantity generator)is true. M Qay y5ar <br /> Exporter I certify that the contents Of this consignment conform to the terms of the attac tor)or(b)(it I am a I small qu; <br /> identified in 40 CFR 2, (if I am a large quantity genera <br /> I certify that the waste minimization statement idei S' nature <br /> Gpn r,t,e Offerors PrntedITYPed Name <br /> ❑Export from U.S Port of entrylexit: <br /> —1 16.international Shipments L-J import to U.S. Date leaving U.S.: <br /> ;-- <br /> rter signature(for exports only): <br /> Mon Day Year <br /> Transporter A, 0\.Aedgment of Receipt of Materials Signature <br /> W- 17.Transporter Ac Mo th Day Year <br /> LLA Wckter I Printed yped Name <br /> Tran <br /> 0 signature <br /> CL <br /> Trarisporter2 Printed[Typed Name <br /> ............................. ...................... .... <br /> Dull Rejection <br /> ElPartial Rejection <br /> ❑Residue <br /> 18.Discrepancy El Type <br /> 18a.Discrepancy Indication Space ❑ Quantity <br /> Wanifest Reference Number <br /> Number <br /> 8b.Alternate Facility(Or Generator) <br /> Month Day Year <br /> CJ <br /> Facility's Phone: <br /> C3 18c.Signature of Alternate Facility(or Generator) <br /> LU <br /> recycling Systems) <br /> treatment,disposal,and rec <br /> Z codes for hazardous waste trea 4. <br /> 0 ig.Hazardous Waste Report Management Method Codes(i.e.. 3. <br /> 7) 2. <br /> W <br /> 0 1. <br /> by the manifest except as noted in Item 18a Month Day Year <br /> tion of receipt of hazardous materials covered <br /> 20,Designated Facility owner or Certification Signature <br /> PrintedfTyped Name GENERATOR'S INITIAL COP <br /> -A c—R7n()-22 3-05) Previous editions are obsolete. <br />