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Please print or type, (Form designed for use on elite (12-pitch) typewriter,) Form Approved. OMB No. 2050-0039 <br /> UNIFORM HAZARDOUS 14 Generator ID Number 2, Page 1 of 3. Emergency Response Phone 4, YA I anifestTrsc ng Number <br /> WASTE MANIFEST ( , # i u i) ,` 1 ( 6ON Ji ) 42?4i : 300 017 6 9 5 3 2 9 JJ K <br /> 5, Generator's Name and Mailing Address Generator's Site Address (If different than mailing address) <br /> r l` ( UtA f CAr % I' H Ni', r LC 'r Pit <br /> Generators Phone: (t 1 � A <br /> 6, Transporter 1 Company Name U.S. EPA ID Number <br /> L...:z <br /> _ j 6AIJ0 b t Cf ] i <br /> LD 'Jlh. C, N vld %VAi ''lEi'r' IAL' E,.:rWVIG <br /> 7, Transporter 2 Company <br /> yName U.S. EPA IDNumber <br /> tpiU roIDW RECOVERY <br /> CAROUld1 <br /> 1 54 d_ L <br /> 8. Designated Facility Name and Site Address U.S. EPA ID Number <br /> c s <br /> � Ileo tr .`, t( i '04V AY :' SS <br /> t l, tiir=, AZ <br /> Facilitys Phone: 0 ~ A J , eq <br /> ga, 9b. U.S. DOT Description (including Proper Shipping Name, Hazard Class, ID Number, 10, Containers 11 , Total 12 Unit 11 Waste Codes <br /> HM and Packing Group (if any)) No. Type Quantity Wtivoi. <br /> z 2. <br /> W , <br /> C7 <br /> I I <br /> 3. <br /> 4. <br /> r <br /> 14. Special Handling instructions and Additional Information / lop <br /> c ., .. , t - �� �a . , .. t ; E ,., tFi � a 7 i '( i PF:< <3� , wC X31 <br /> l" R6 17RA f 6 BRAKE ii li .;� i—fa�� HNC# ." r; I ` I� , i .J i"' Y" i1t 1= , ` C ' Ci in �.{ .; i " (i ( :. <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, packeded, <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 (his consignment conform to the terms of the attached EPAAcknowledgment of Consent. <br /> I certify that the waste minimization statement Identified in 40 CFR 262627(a) (if I am a large quantity generator) 2 ' I am a ynall quantity generator) is tare. <br /> rtor`s/2!e!ro Pr(nted/Typed Name Signatur Month Day Year <br /> !' eeter• <br /> F 16. intema I Shipm <br /> ❑ Import to U.S. ❑ Export fro Port of entrylexiC <br /> 00 <br /> z Transporter signature (for exports only); Date leaving U.S.: <br /> 17, Transporter Acknowledgment of Receipt of MateriaLAJ <br /> ls <br /> Trans. r 1 Printed/Typed Na Signature Month Day Year <br /> n. <br /> z nsponer 2rintedrTyped Name Signatur Month Day Year <br /> v ,•.-- �G <br /> 18, Discrepancy <br /> 18a. Discrepancy Indication Space ® Quantity ❑ Type ❑ Residue ❑ Partial Rejection ❑ Full Rejection <br /> Manifest Reference Number: <br /> 18b, Alternate Facility (or Generator) U.S. EPA ID Number <br /> J <br /> U <br /> sem+- Facility's Phone: <br /> u 18c. Signature of Alternate Facility (or Generator) Month Day Year <br /> N19. Hazardous Waste Report Management Method Codes ( .e., codes for hazardous waste treatment, disposal, and recycling systems) <br /> G 1 , 2. <br /> 3. 4. <br /> 20, Designated Facility Owner or Operator: Certification of receipt of hazardous materials covered by the manifest except as noted in Item 188 <br /> Printed(Typed Name _ VGA Signature Month Day Year <br /> J!L�/Iwda ( MXhL- - — it V <br /> EPA Form 870042 (Rev. 3-05) Previous editions are obsolete. DESIGNAT& FACILIT O DESTINATION STATE (IF REQUIRED) <br /> E <br />