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Form Approved.OMB No.2050-0039 <br /> Please pgriro�iype.(Form designed for use on elite(12-pitch)typewriter.) 4.Manifest Tracking Number <br /> HAZARDOUS1111111�1 I 7q - <br /> 7Z!� �=4. <br /> Generator ID Number q 2.Page I of 3.Emergency Response Phone <br /> 7 s1 <br /> JJK <br /> UNIFORM <br /> 0 <br /> Wfl:'S"TE MANIFEST z, Generator Site Address(if different than mailing address) <br /> 5.Geriptoes Na,n Mailing Address <br /> )a and Mailln <br /> LtV <br /> Generators Phone( U.S.EPA ID Number <br /> 6,Transporter 1—Company Name <br /> t-Al!CUP:�62 096 <br /> KXAN EvlIt IC Number <br /> 7.Transporter 2 Company Name CAL 0,10 365 1113 <br /> a.,EglgFte is aqd She Address U.S.EPA ID Number <br /> L <br /> 1,Tr t� <br /> ,j,ia Ia.crtt fn s5 F <br /> ? 41 <br /> I fit)"-,VC&c <br /> Cr i1 -4 CC, <br /> '2 <br /> f. <br /> Facili_ s Phone: rxCi-77A-61`!s �-,- <br /> 9a. 9b.U.S.DOT Descdp6on(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit 13.Waste Codes <br /> HM and Packing Group(if any)) No. Type Quantity M.Nol. <br /> ........................ <br /> ............... <br /> A' <br /> 1- &4 <br /> 0 <br /> C- <br /> -77 <br /> f7 <br /> Uj 16 <br /> 377A"—i,- <br /> 3. <br /> 4. <br /> 14.Special Handling Instructions and Additional information 1A <br /> VIM-,kpf' 352., Uttltart.Mifivte�sttaaq, <br /> 5. GENERATOWS/.OFFEROITS CERTIFICATION:I hereby declare that the contents of this consignment are fully and accurately descdbed abornve by the proper shipping nass <br /> me,and are claified,packaged, <br /> marked and labeled/placarded,and are in all respects in proper condition for transport according to applicable intematonal and national bed regulations.If export shipment and I am the Primary <br /> Exporter,I certify that the contents of this consignment conform to the terms of the attached EPAAcknowledgment of Consent. true.I certify that the waste minimization statement identified in 40 CFR 262.27(a)(if I am a large quantity generator)or(b)(d I am a small quantitygenerator)is a. Month Day Year <br /> Generator s/Offeroe.s Pi <br /> intedrTyped Name Signature 49 1 <br /> -j 16.I1 ftemational Shipments El Import to U.S. El Export from U.S.t r Port of entrylexit <br /> Date leaving U.S.: <br /> Transporter signature(for exports only): ... <br /> X 17.Transporter Acknowledgment of Receipt of Materials .9 Month Day Year <br /> Uj Signatuo <br /> t2 Transporter 1 Printed/Typed Name <br /> S <br /> 1,z" <br /> 0 , <br /> 1116 V/I I fl k /11 ,11) -,1 Month Day Year <br /> to �jgrdwp-J7 <br /> Z Trans er 2 Pirmted[Typed Name I- <br /> 7 <br /> C,/x <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space m.nfity ❑Type ❑Residue ❑Partial Rejection El Full Rejection <br /> hA--if--t Reference Number. <br /> U.S.EPA ID Number <br /> 18b.Aftemate Facility rGenerator) <br /> Facility's Phone: Month Day Year <br /> U1 18c.Signature of Alternate Facility(or Generator) <br /> Z <br /> 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> ..........13. 4. <br /> 012. <br /> Facia Owner or operator.Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a Mo Day, <br /> Sig lure, <br /> Year <br /> Print ypeO Name ��j <br /> (0�It <br /> E 3A F6rffi 11 87W-22(Re 5) Previou)editions are obsolete. FACILITY T.0 GENERATOR <br />