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-All <br />plaise aiatot Whiff- (Form aisio'he'd for use on alita (12-nitch) hnwAtArl <br />DTSC. 029.53. 0'3'-9-a <br />F— Annrnvad- 0MR No. 2ffi(1.M19 <br />tVA I-Offn WUU-Zi (Kev. jw) Previous eamons are wsoiete. DESIGNATED FACILITY TO GENERATOR STATE (IF REWIRED) <br />11889.1545 <br />Y <br />UNIFORM US <br />WASTE :AAAZ <br />FEST <br />1 1. Generator D Number <br />age 1 df <br />Emergency Response Ption <br />-7 <br />4. Man ftst Tracking Number <br />1 011279771 JJK- <br />MC*nemames e and Mang AM Site Address (d different than inaft address) <br />000 V%& <br />6-fock--h-", 44 95zos - <br />.Generates Phom 2-ocl 4. sb-a— <br />Sransporter I06mpany Name U.S. EPA ID Number <br />t' tit rilic, <br />7. Transporter 2 Company Nam U.S. EPA ID Number <br />Qa%Facfl ity Me and Site Address U.S. EPA ID Number <br />,,,. <br />Gr <br />t.� C- <br />115 0 M4--rp 4-, <br />00 <br />:F adlitys Phone: -22 _ Z. <br />9a.. <br />HM <br />90. U:e. DOT Description (mcluift Proper Shipping Name, Hazard Class, ID Number, <br />and Packing Group (if ahy)) <br />10. Contalm's <br />it. Total <br />1 . 2. Unit <br />Ii. Waste Codes <br />No. <br />Type <br />Ouantfty <br />WtNol. <br />0: <br />o <br />ass <br />911-1, <br />W <br />0 <br />EFT> 0 -P*MaA L - 'ar; <br />3. <br />4. <br />.14. Special Handle I structioris ®and Additional Information <br />gn <br />csq - <br />ai, <br />A -W kp-:2 US <br />15. GENERATORWOFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by Me proper shipping name, and.dre.classilled, packagail, <br />marked and labs ed, and are in all respects In proper condition for transport according to applicable International and national governmental regulations. If export shiphmt and I am the Primary <br />Exporter, I ce* that the contents of this consignment conform to the term of the attached EPAAdmowledgment of Consent. <br />1 certify that the waste minimization statement identified in 40 CFR 262.27(a) (if I am a large W* generalor) or (b) (If I mall quantity general") is he. <br />[GeneraWesfOffmr!sPrInt4Ty*Naive ,Signature Month. Day <br />t it 0 <br />-d <br />16. InteMMaMhWhOW 0 Import to U.S. ❑ EV -d Port of entryraift <br />VU <br />Transporter Signat— (Ibr.-I)Ortir Only): Date leaving U.S.: <br />17. TransporterAcknowledgimmi of Receipt Of Materials <br />Transporter 1 PdntedfType Name Signature Day ydar <br />Month <br />R <br />pf <br />z <br />Trans poft it Name signs Month Djy, Yjq <br />24 <br />18. Discrepancy 71 <br />18s. Discrepancy Indication Space El Quantity El Type Reskiiiii V M P.,., 111kelon ❑ Full Rejection. <br />Manifest Reference Number <br />18b. Alternate Facility (or.Genarator) U.S. EPA ID Number <br />Facilitys Phone: <br />18c. Signature of Alternate Facility (or Generator) <br />Month Day Year <br />co <br />ig. HaZardouS Waste Report Management Method Codes (Le., codes for hazardous waste treatment disposal, and recycling system) <br />20. Designated Facility Owner or Operator Certification of receipt of hazardous materials covered by the manifest except astdad In hem 18a a <br />Printediffyped Name SignatureMom-10- Day Year <br />/* <br />tVA I-Offn WUU-Zi (Kev. jw) Previous eamons are wsoiete. DESIGNATED FACILITY TO GENERATOR STATE (IF REWIRED) <br />11889.1545 <br />Y <br />