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f �� LFII I N 111 <br />Please print or type. (Form designed for use on elite (12-pitch) typewriter). Form Approved. OMB No. 2050-0039 <br />UNIFORM HAZARDOUS <br />1 Generator ID Number <br />2. Page 1 of <br />3. Emergency Response Phone <br />4. Manifest Tracking Number <br />008681048 C <br />MANIFEST <br />= EWASTE : 444 <br />L C <br />5. Generator's Name and Mailing Address Generators Site Address (if different than mailing address) <br />Generators Phone: "' <br />6. Transporter 1 Company Name U.S. EPA ID Number <br />Sro i.- <br />7. Transporter 2 Company Name U.S. EPA ID Number <br />i <br />8. Designated Facility Name and Site Addressi_t..- U.S. EPA ID Number <br />SiFacility's Phone: = 635 1 09AZ <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 />13. Waste Codes <br />No. <br />Type <br />HM <br />and Packing Group (if any)) <br />Quantity <br />Wt./Vol.' <br />`1. <br />ks ,t�m. ?F=; C.+w (, ".. Ct.V.C,� _:i 1.: e, fi ^r.: Y.q$-, 3iww {'�6'4 �.`fr'__. <br />ism <br />., <br />fY <br />O <br />3� q <br />Y .. .. _ may.. .r, .. c,:a tv§ac t.7 .P. 2 �; y R!..•YY 12 <br />W <br />Z <br />ee; f ♦ Yr f� <br />2. �fL;: �i _ _ .- ... �,: d- Pte. 3.� ii. 'S °� c. ? ,. .. `-e i f .. i� t" <br />" <br />W <br />Pr 3,'d r- f 'ia -s 1 <br />3. <br />4. <br />14. Special Handling Instructions and Additional Information <br />..n Zy ?.i s.R �S Y•�LL j•w�` .rte. <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 certify that the waste minimization statement identified in 40 CFR 262.27(a) (if I am a targe quantity generator); or (b) (if I am a small quantity gene tor) is true. <br />Generators/Offerors PrintedfTyped Name titgnature on ay Year <br />F- <br />If. International Shipments <br />El Import to U.S. ❑ Exporffrom U.S: Port of entry/exit: <br />7, <br />Transporter s' naturg for exports only): Date leaving U.S.; <br />17 Transporter Acknowledgment of Receipt of MaterialsUj` <br />Transporter 1 Pdntedfryped Name nature - Month ay Year <br />Z <br />Transporter 2PrintedrlypedName Sign re Month Day Year - <br />H <br />18. Discrepancy <br />18a. Discrepancy Indication Space ❑ Quantity ❑Type: ❑ Residue ❑ Partial Rejediori ❑ Full Rejection <br />Manifest Reference Number. <br />18b. Alternate Facility (or Generator) U.S. EPA ID Number <br />J_ <br />V <br />L <br />Facility's Phone: <br />W <br />18c. Signature of Alternate Facility (or Generator) Month Day Yeah <br />Q <br />Z <br />19. Hazardous Waste R port Management Method Codes (i.e., codes for hazardous waste treatment, disposal, and recycling systems) <br />W <br />O <br />1 <br />41q( <br />2. <br />1 s4:jq <br />3 <br />4 • =: <br />?.: <br />20. Designd Fa 'lity Owner or Operator. Certification of receipt of haze dous matedalscpveredPy the manifest except as n2L.4 in 09 18a <br />Pri ped Nam Signatu <br />EPA Form 8 22 (Re , 3-05) Previous editions are obsolete. DE GNATED FACILfTY TQ. TINATION <br />