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Please print or type. (Form designed for use on elite (12-pitch type rites) Form Approved, OMB No. 2050.0039 UNIFORM HAZARDOUS 1 . Generator ID Number 2. Page 1 of 3. Emergency Response Phone 4. Manifest Tracking Number WASTE MANIFEST : a JJK 5. Generators Name and Mailing Address Generator's Site Address (if different than mailing address) � ) IJ Generator's Phone: j 6, Transporter 1 Company Name US, EPA ID Number c � t lll =3 z 7. 7ransporter 2 Company Namei U.S. EPA ID Number 8. Designated Facility Name and Site Address U,S. EPA ID Number pl 1 . 1 iptAt It e , Sri 3 ,r,3J } b sI „ Y . G int Facility's Phone: gat 9b. U.S. DOT Description (including Proper Shipping Nary e, He and Class, ID Number, 10. Containers 11 . Total 12. Unit HM and Packing Group (if any)) No. Type Quantity Wt.Nol,loom 13. Waste Codes 1 . , � ” 3 0 r , Z 2. LLI 7 g C7 I 3. 4. 14. Special Handling Instructions and Additional information Al lip t u s `sn t. dd , Y 15, GENERATOR'SIOFFEROR'S CERTIFICATION: I hereby de tare t at the contents of this consignment are fully and accurately described above by the prier name, and are classified, packaged, marked and labeled/piacarded, anri are in all respects in prop ` r con ition for transport according to applicable international and national governmental regulations. If export shipment and I am the Primary Exporter, I certify that the contents of this consignment confo to t e terms of the attached EPAAcknowledgment of Consent. I certify that the waste minimization statement identified in 40 FR 62.27(a) (if I am a large quantity generator) or (b) (if I am a small quantity generator) is true. Generator's/Offeroes Printed/Typed Name Signature Month Day Year S V z a 1 1 % _r 16. International Shipments a'- ❑ Import to U.S. ❑ Export from U.S. Port of entry/exit: TranspoPANNOMP"Inirter signature (for exports only): Date leaving U.S.: W 17. Transporter Acknowledgment of Receipt of Materials Transporter 1 Printedlfypad Name Signature Month Day Year � Transporter 2 Printed/Typed Name Signature Month Day Year F- 18. Discrepancy 18a. Discrepancy Indication Space ❑ Quanti}y ❑ Type ❑ Residue ❑ Partial Rejection ❑ Full Rejection Manifest Reference Number: J 18b, Alternate Facility (or Generator) U.S. EPA ID Number L) W Facility's Phone: w 18c. Signature of Alternate Facility (or Generator) Month Day Year B 19. Hazardous Waste Report Management Method Codes (i.e., cod " s for iazardous waste treatment, disposal, and recycling systems) UJ 1 �1119 r' 1 ., 2. 3, 4 20. Designated Facility Owner or Operator: Certification of receipt o haza ous materials covered by the manifest except as noted in Item 18a PnntedlTyped Name Signature Month Day Year EPA Form 870011 (Rev. 3-05) Previous editions are obsolete. 3 t i 'BIIGNWE.51 FACILITY TO GE FR3ATOPI