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AUG 0 -'0 13 <br />Please icTint or tvDe- I Form dpqinn-I frn—— .1A. <br />a � Number corm Approved. OMB No. 2050-0039 <br />UNIFORM HAZARDOUS <br />DES—IONATEOFACILI!i 7G GENERATOR <br />1. Gene ID N Pa ilt- - — <br />u NanifestTrdcki Numbed <br />4. !�Resp <br />J4. <br />WASTE MANIFEST <br />-ST <br />J K <br />Gamirilli Sft Address (if diflierent than mailing address) <br />MN- 1 FC45MUVj'. F—e Ky'-w-t2 K'ra F 0 5 F? <br />0A Oif 47, <br />T <br />Generafor's Phare: <br />6. Transporter I Company Name U.S. EP A ID Number., <br />G - <br />7. Transporter 2 Company Name U.S. EPA ID Number <br />8. Designated Facillty Name and le <br />r::`;NRCJPi1 'e 1 d' U.S. CPA ID Number <br />OMN IP - SFRMCES <br />Nftp. KV 3 <br />CA 9�-It9l $3 f Jr -i (f 6V 3 <br />0 ! 6137 1 -ai-4 <br />Facility's Phone: <br />ge. <br />9b. U.S. DOT Description (including I oper Shipping Name, Hazard Class, ID Number, <br />10. Containers <br />ii.Total <br />12. Unit <br />t13. <br />HM <br />and Pack ng Group (if any)) <br />Quantity <br />WI-Nol. <br />Waste Codes <br />No. <br />Type <br />0 <br />101US th"NSTE, U QU I P. D or I PiNVE6 C 1 t <br />2f <br />111 <br />2. <br />LD <br />3. <br />4. <br />14. Special Handling Inshiclions and Ad 0 information <br />_ - 4 -ffl : DKIMIOR WP 'K ON 'F M-4244-(np- <br />F U GENCYCOW ;T. EfNOW�:Cf <br />'NTROPRIAW FRCY F Si F <br />15 GENERATOR'SIOFFEROR'S CERTIFICA17ON: I hereby declare that the conients of this consignment are fully and accurately described above by the proper shipping name, and are classified, packaged, <br />marked and labelLdtPlErGarded, and are in Oil 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 olinsignment conform to the terms of the attached EPAAcknawledglinant of Consent. <br />I certify that the waste minimization stafemiIiii Identified In 40 CFR 26U7(a) (d I am a large quantity generator) or (b) (WI am a small quantity generator) is true. <br />Generalors/Offerou's PnnlTy d Name Signature Monlh Day Year <br />16. International ShIpments UkA+:1DILk& ❑ Export f,.,,. U.S. Porto. <br />. I <br />Transporter signature (for exports ofilYY Date leaviing U.S.: <br />17. Transporter Acknowledgment or Receipt of ME lienais <br />•Month <br />Transporter_, iflintedfTyped Name I I Signature Day Year <br />Z <br />Transporter 2 Pyintedffypl,Name Signature Month Day Year <br />18. Discrepancy <br />16a. Discrepancy Indication SpacentY LITYPe El Residue El Partial Rejection El Full R*dkn <br />Manifest Reference Number <br />18b. Alternate Facilty (or Generator) U.S. EPA ID Number <br />na <br />Faahlys Phone: <br />LLj <br />1Bc- Signature ofAllemate Facility (or Generator)7on <br />th Day Year <br />0 <br />19. Hazardous WasleReport Management Method Codes (.e., codes for hazardous waste treatment, disposal, and recycling systems) <br />112. <br />3. <br />4. <br />20. Designated Facility Owner or Operator. Cerfificirlip. ofreoe0of hazardous malBdals covered by the rn2rifestexoep(64n0iidb�kiim10a <br />FlririteclT ped NFmi I <br />, (- I , .. I, , "I Signature <br />A, ly <br />DES—IONATEOFACILI!i 7G GENERATOR <br />