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Please orinl or tvnp (Fnrm ripcinnwi fnr iii. I - -.1 v1.- 1- -) Gulu.jm 7 U u1"l * I 1 `c I (I I I ( i DES GNATF_D FACILITY TO GENERATOR - - UNIFORM HAZARDOUS 1. Genera WASTE MANIFEST i _ _...._.., . . ,. .� d UM m prove o. - D Number 2. Page 1 of 3. Emerg Response Phone 4. Mandevivracking Number 9 ks 2 0, ii 2 t7 'I �` a 6-8 n06-821,32;'6-2--it IS -10t)) L241-9L?f?'v- 6- d • e 0 : 3 JJ K 5. Generato s Name and Mailing Address , 2;' --i Generatoes Site Address Of different than marling address) v i> 4 i"wEsi'f i�L'EL 117,i3'Fi,`L� N E8r,- T CPA -9V47 Generator's Phone: •�r`r` r3 _ ':;�.d 6. Transporter 1 Company Name U.S. EPA ID Number ee: ��Ei1� � s;; r t3 f3 r L 2 ? ? rl :F ei 77aspr 2Compa�n;y�;;-,;�I;;p,'r•.t. Name U.S. EPA ID Number ,c- aled Facility Name and Site Addres !,f C - •� SEP ID y�ukm U✓ U.S. A umber��_�;` `>L ,. fN� iSfS So"L�t�lti\J �✓} ;.,y.� l E: r^yt .. ..-._--. o W(.$ 5t6 - U1.IYWYht 4f 1 J C r� 'l 6 t .� rr -i �tt`"1^3il_..._ Facility'slG -r:`---.a.•-•fr-�'—•f�--ICS.r.2--^z:-•"+4-3•-"� U �i 1 `- �Z 9a. 911 U.S. DOT Description (including r Shipping Name, Hazard Class, ID Number, 10. Containers 11. Total 12. Unit HM and Packing Group (If any)) Quantity M.Nol. I& Waste Codes No. Type. � 1 Q -ti0l'-Ri'1 u1y%3^ US WASE. iIUH) 0 (ALN -'C-0 (A LLJ M 2. W 3. i 4. i 14. Special Handling Instructions and Adddio Information i'LAEi'<i�-,t X93 : Id''i " '�(!�, :E#90i tJt�.�?'OM ENERGEW;Y CONTACT GREW REG"U-r24-93W ;!�.�s #;�$�iEr�.,ci?;-'�•�1`:�'- t1�R r`�r itCf':4.'� F� ;FS : Ro i : , iq xn:: ' <'Fs" fi`;4� s �8rRA -es, it -T E�t'tlf ; ! 15. GENERATOR'SIOFFEROR'S CERTIFIC ION: ! 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/piacarded, and are in Exporter, certify- [hat the contents o(dris II respects m proper condition for transport according to applicable international and national governmental regulattons. If export shipment and I am the Primary s ZIrst conform to the terms of the allached EPAAdAowiedgment of Consent I certify that the waste minimization statem nt identified in 10 CFR 26227(a) Of I am a large quantity generator) or (b) (cit am a small quantity generator) is the. Generatots101fercr's Printe&7yped Name I ` 55 Signature _ - .4 Month Day Year N,, , �..-. /--. n— 16. International Shipments I I b U.S. ❑ Export from U.S. Pon o� entry/exit: Z Ttansoorter sl nature for ex orfs m 9 ( P h) to Date ,avh g U.S.: Ll 17. Transporter Aclmowledgmenfof Receipt of M eriats _ ; •,� Transporter 1 Pdntedllyped Na T-' SignaWe ) ' ; 4 Month Da Year 1 Y Q Transporter 2 P nled/iypg/i Name Signature t Month Day Year 18. Discrepancy 18a. Discrepancy indication Space C. tity ❑ Type ❑ Residue ❑ Partial Rejection ❑ Full Rejec8on Manifest Reference Number. 18b. Alternate Facility (or Generator) U.S. EPA ID Number U I Facility's Phone: 18c. Signature of Akemale Facility (or Generator) MonUt Day Year Q z 19. Hazardous Waste Report Management Me Codes (i.e., codes for hazardous waste treatment, disposal, and recycing systems) .� 2. ....) 4- 20. Designated Fecitly Owner or Operator. Certition of receipt of haiardous materials covered by the mandesl except as noted In Item 188 Pnnted/Ty Name t -I ,Sgrelure' Montle Day .:veer tA I - -.1 v1.- 1- -) Gulu.jm 7 U u1"l * I 1 `c I (I I I ( i DES GNATF_D FACILITY TO GENERATOR