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3 .1 <br /> Please print or".(Form desi ned for use on®lite,12•pitch)typewriter. F°rmAppr°ved'aFP N°'.2 <br /> UNIFORM HAZARDOUS i.Generatw IQ;NtxOt� 2.Page 1'of 3.Emergency Response Phone. 4.Atani1 Traclan Nmnber <br /> WASTE MANIFEST 4Ai.e,'0l. , 1 " ' `7i�:`=-'rn`2 �D ,2 JJ. <br /> 5.Germatots Name and MaiingAddress Gene-atars SbAddress,(d different than meding address), <br /> BELKORP Jig. I1120 41.11,iN iii.•VIVA'ir i <br /> P.O.Bax _ <br /> SMCKMN.CA, 1 <br /> Geneiatoes Phone d!a• U.3.EPAID Number ' <br /> 6.Transporlerl Cgmpanyny_Narr� <br /> WL <br /> 7.Transporter Company Name to VA.WU.S.EPA ID Number <br /> 1.Designated Facility Nam and Sib Address U.S.EPA ID Number'02 <br /> _ <br /> Iwo t::-BRUMAGE La.. ENVIRONMENTAL <br /> '�DEPARThAENT <br /> Fact' Phone: <br /> ' ALIIJ9a. 9b.U.S.DOT Desmon fmdudng Proper Shipping Name,Hazard Class,ID Number - 10.Cgntaicets 11:Total 12.Unit 13.Waste Codes <br /> HM and Packing Group.(d em)1 _ •No. Type <br /> Quantity 1NtJtkl. <br /> O 1. °l�f! '?,^. 4.N<��Ai lr'��f?S 'i�t!4:r� 'at?tJCt +Cftw`. Fri Ftp psi 1 0141 <br /> { <br /> 2 2. E`I <br /> 3. <br /> f <br /> 4. <br /> . I <br /> 14.Special Handing Insludioos andAddWwd infofmation. <br /> tolV i s c�;.{+r P•M*a Yi/.y r,/1 4+ tia.::rb..r <br /> 2-373 ) <br /> 15,,TGENERATOR'S/OFFEROR'S CERTIFICATION:I hereby declare that the contents of this consignment are fully and accurately described aloe by the proper s'ppng[came,and are dassrAed'packaged' <br /> marked and labeladlplacarded,and are in all respects in proper eoncfition for transport according to applicable international and national governmental regulations.If export shunt and I am the Primary <br /> Exporter,I certify that the contents of this consignment conform to the terms of the attached EPAAcknowledgment of Conant. <br /> I'cs*that the waste minimization statement identified in 40 CFR 262.27(a)(if I am a large quantity generator)or(b)(dl am a small quantity generator)is true. <br /> rator'sf0lfe Month Day Year <br /> Gene <br /> Lt f R g� Signature ""'.. 1 F 3 f <br /> -:r 16.International Shunts <br /> F_ Q Import to U.S. ❑Export finnn US. Port le ving U.S.: _ <br /> z <br /> Transporter mature(for exports o>Ey):. Aare heaving U.S. <br /> L 17.TransporterAckvowledgment of Receipt of Materials <br /> Transporter 1 P me Signature <br /> 0 <br /> QTranporter4 dName Signature Month Y§m <br /> 18-Discrepancy <br /> 18a.Discrepancy Indication Space F1 Qu�� ❑Type ❑Residue ❑Partial ❑Full Rejection <br /> Manifest Reference Number. <br /> U.S.EPA ID Number <br /> I 8b.Alternate Facilty(or Generator) <br /> ...r <br /> v <br /> t4L Facility's Phone: Month Day Year <br /> 18E Signature o Remate Facilty(w Generator) <br /> CD <br /> 19.Hazardous Waste Report Management Method (i.e.,codes for hazardous waste treatment disposal and recycling systems) <br /> 65 .Uj 2• 3. " 4. <br /> 0 1 J 1 <br /> I <br /> 20.Designated Facility Owner or Operator.Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a Ye <br /> PrintedfTyped Name " Signature. Month Day ar <br /> I <br />