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N—I <br />F. Annmvad- OMB No. 2060-0039 <br />F -PA 1-0(1`n IJIUU-Zz (Kuy- )-vu) r icy' -v - <br />DESIGNATED FACILITY'S COPY <br />or type. (roan u-91— w—.,,r------- --- — <br />Numba 2. Page 1 of 3. Emergency Response T—Manifest -Ir—acking Number <br />1. k�A�e��nnff nse Phone <br />7911 <br />UNIFORM HAZAICIOUS1 GBF <br />WASTE MANIFEST I . - (-.AL(jt)fj j W09) —11 OXI-146-74411 <br />--- <br />5. Generators Name and Mailing Address Generators Site liflem, th- mailing address <br />r-oRvyARD LOIDI-Ilt- <br />P-C, tiox aw, 99W C AUS 1-114 IRE) <br />Generators Phone:7159-14'3 -1 2ft 1 U.S. EPA ID Number <br />—Company <br />6. Transporter I Name <br />FI4CP OVARDS SfX- 011 ONS, CAt7iif71a53fi�y 'r <br />7. Transporter 2 Company Name U.S. EPA til Number <br />a. Designated Facility Name and Site Address p.S.'EPA ID Number <br />6BARAWHO 000DOVA. ILL -C <br />i-JE12% "ilE WXV RI*N <br />RWICHO CORI"'A, CA 0674'� <br />FaLifity's Phone: <br />9a. 9b. U.S. DOT Description (Includirg Prorper-Shipping Name. Hazard Class, ID Number, 110. Containers it. Total 12. Unit 13. Waste Codes <br />HM' and Packdag Group (I any)) No. Type Quantity ".No(.— — <br />I4()WR--RA HA �-RDQIJS XASI- V-412ODD <br />CAA <br />2 0,� <br />-P <br />nn <br />Wit' NTS, RAGS >S (.41- <br />2, <br />LU <br />3. <br />O <br />4. <br />14, Special Handling instructl a and Additional Information <br />PROV-111- #142-M61 <br />APr4;N-VRATE PP()TEV-Tl\+. CLOTAG <br />SEFERG071 <br />15. GENERATOR'SIO FERORIS CERTIFICATION: I hereby declare that the contents Of this consignment are fidly and accurately described above by the Proper shipping ' name, ard are classified, packaged,the Primary <br />ff export shipment and I am <br />marked and labalecli'plararded, and are In all respects in proper condition for transport according to applicable International and national govemm anted regulations. <br />Exporter, I certify that the contents of this consignment conform to the terms of the attached EPA Aduowledgment Of Consent. <br />I certify that the waste minimization statement Identified! in 40 CFR 262.27(a) (if I am a large quantity generator) of. (b) (if I am a smal quantity gener, <br />------- m— - - Month Day Year <br />---------- --- - <br />me <br />p <br />�Genaratoesl(Yffero�.es �Pdtte <br />;at <br />—1 <br />international Shipments <br />❑Import to U.S. ❑ Export from U.S. Port of entridexit <br />P- <br />Transporter signature Date leaving U.S.: <br />LU <br />17. Transporte-Acilknowledgment of Recisiptol materials <br />Dai Yaar <br />Mon <br />12 <br />Trans drdediT me 51gn <br />0 <br />n- <br />Month)ay Year <br />Ira pDrter.2 P Name Signature <br />18, Discrepancy <br />18a. Discrepancy Indication Spare Quantity ❑ Type ❑ ResidueRejection❑ ❑ Full Rejection <br />Manifest Reference Number. <br />18b. Alternate Facility (or Generator) U.S. EPA b Number <br />(JI <br />F.6[iWs Phone: Month Day Year <br />18c. Signature of Alternate varinty (or Generator) <br />19. Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste treatment, disposal, and recycling systems) <br />LU <br />11111112. 3. 4. <br />materials covered bythe�..ft..pt.,,nddin.he.18-�- <br />20. Designated Facility Owner or Operator. Certificationof receipt of owi h�anrdous <br />y <br />Signature <br />A P1 wil -it " nUNi <br />t (�il <br />F -PA 1-0(1`n IJIUU-Zz (Kuy- )-vu) r icy' -v - <br />DESIGNATED FACILITY'S COPY <br />