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Please print or type, Form Approved,OMB No.2050-0039
<br /> UNIFORM HAZARDOUS I'.Generator ID Number 2,Page 1 of 3.Emergency Response Phone 4,Manifest Tracking Number
<br /> WASTE MANIFEST fAi-tJ[}U t k?E f.} j 3C} x fST1 ,` � G F
<br /> 5.Generator's Name and MailingAddress Generator's Site Address(if different than mailing address)
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<br /> (MV PtNEGRE 9 i'.}fit Jb'!'la:XJOQ63154 i,k i dt tt P #:3! ...
<br /> ���.1��'�8t�}, EX, "1'6024 S�t"�"�f„;Er;`i"'�?3ei,GA '0ti:�C,l6
<br /> Generalces Phonq'-lek'm*�a
<br /> 6.Transporter 1 Company Name U.S.EPA ID Number
<br /> 11li.l tSt:e 3 VALLEY WA.:YTE Olt, VIC. Cla, t'J i Y2772:t V
<br /> 7,Transporter 2 Company Name U.S.EPA ID Number
<br /> t l£:.6tic"YCLE,113a}E.O1A7.fY Aa T � 1 t^P.;�,ll$C> flit ktiGTf,#f 10224
<br /> 8.Designated Facility Name and Site Address U.S,EPA ID Number
<br /> tA3.3`i�•j°tAtr�d;."kitf�:�,�#t}'�tD1��%,X1.4.;'.
<br /> -1A5 VVI,11TIEOC,KAD
<br /> I'ZAtrlt,d'FtO,':ORWVA,CIA W1.42
<br /> Facility's Phone I t3 qty 4'LYt�S�}
<br /> 9a. 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10°Containers 11.Total 12.Unit 13.Waste Codes
<br /> HM and Racking Group(ifany))
<br /> tyy�1 No. tType Quantity Wt.Nol.
<br /> '� 1. ;!t':�i. 4.fC f°#}:t(i iRft��53T'F-.}"t 11';�'`f_.,f�gaJIArl llt,}t.sr1 )�+E VIN�'��IC�E,3,li1., 7 $_110 1110 0001 ;:`I
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<br /> 3.
<br /> 4.
<br /> 14,Special Handling Instructions and Additional Information
<br /> PR+F11i 14300976-00 J r K)K:AWAt`rcAM K-A, m-X-w 12
<br /> 15. GENERATOR'S10FFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are hilly and acourat6ly described above by the proper shipping name,and are classified,packaged,.
<br /> marked and Iaboled/placarded,and are in all respects In proper condition for transport according to applicable international and national governmental regulations.If export shipment and 1 am the Primary
<br /> Exporter,I certify that the contents of this consignment conform to the terms of the attached EPAAcknowledgment of Consent.
<br /> I certify that the waste minimization statement identified in 44 CFR 262.27(a)(if I am a large quantity generator)or(b)(if I am a small quantity generator)is true.
<br /> Generator's/Oif,rbr's P edlTy ed Nam/e'"`' Signature,,,.,., s Month Day Yqar
<br /> ���3 ry �4 f ."7 V' r. k'�i " t� ,.;.S,.�e..w...,w..•^.�""'...- �."y f ir�'�:�.
<br /> -j16.intemationalkShipments
<br /> r°.., ❑Import to u.8. ❑Export from U.S. Part of entrylexlf:
<br /> A Transporter signature(for exports only): Date leaving U.S.:
<br /> LU 17.TransportorAdnowledgment of Receipt of Materials
<br /> 12 Tran o0e.11 PrintetllTy ed Name Sign turp , :- pr Month Day Year
<br /> Transporter 2 Printedfryped Name Slgnature x Month Day Year
<br /> 18,Discrepancy
<br /> 18a.Discrepancy Indication Space ❑ Quantity El Type ❑Residue ❑Partial Rejection ❑Full Rejection
<br /> Manifest Reference Number:
<br /> 18h.Alternate Facility(or Generator) U.S.EPA ID Number
<br /> J_
<br /> LaL. Facility's Phone: t`
<br /> Lij 180 Signature of Alternate Facility(or Generator) Month Day Year
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<br /> CD 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems)
<br /> a1. 2. 3. Notice: State of California requires
<br /> generator to photocopy and mail to
<br /> 20.Designated Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except as noted In Item 180 li With:30 days-.
<br /> PrintacilTyped Name Signature P.0 Dox 400
<br /> Sacramento,CA 95812-0400
<br /> EPA Farm 8700.22(Rev.12-17) Previous editions are obsolete. GENERATOR'S INITIAL COPY
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