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Please print or type. (Form designed for use on elite (12-oitchl ewriter.l Cnrm Annm,,,..1clop-1 0 nn ni,, oncn mm� cr,r,rur11ao1vu-2-CtRev.3-091 Previous edWonsare obsolete. UNIFORM HAZARDOUS 1. Generator ID Number, 2. Page1!i ergency Response Phone rr•�• 4 Manifest Tracking Number WASTE MANIFEST iJ Ul 5 Generator's Name and Mailing Address Generator's Site Address (if different than mailing address) >,r } "1"." Generator's Phone: 6 Transporter 1,gompany Name U.S. EPA ID Number a. 7. Transporter 2 Company Name U.S. EPA ID Number 8. Designated Facility Name and Site Address R , s g + t !"A t r to " U.S. EPA ID Number 4R e1 ..< :' �. .. .. .. Facility's Phone: ga, 9b. U.S. DOT Description (including Proper Shipping Name, Hazard Class, ID Number, 10. Containers 11. Total 12. Unit HM and Packing Group (if any)) Quantity Wt.Nol. 13. Waste Codes No. Type wAi=if t•.,AMt1, <{t< i{ erli F, ,_ r i T t'Y 2 UJ 0 i 3. g 4. 14. Special Handling Instructions and Additional Information -,'AV' r -� j P e� p F p p s' , �Y. :*. b.: •, C4. u",_ -#a �f ...' ,.ETAi%a� LIC'ElISE e�>?..t Li _is'u.?,)st?�1 '..-t}'1 ,%iF.; s'e x. ii-. L?, :. �,.' = 15. GENERATOR'SIOFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by the proper shipping name, and are classified, packaged, marked and labeled/placarded, and are in all respects in proper condition for transport according to applicable international and national governmental regulations. If export shipment and I am the Primary Exporter, I certify that the contents of this consignment conform to the terms of the attached EPA Acknowledgment of Consent. I certify that the waste minimization statement identified in 40 CFR 262.27(a) (if I am a large quantity generator) or (b) (if I am a small quantity generator) is true. Generator's/Offerors Printed/Typed Name Signature Month Day Year J16. H International Shipments ❑ Import to U.S. ❑ Z Export from U.S. Portof entry/exit: Transporter signature (for exports only): Date leaving U.S.: UJ 17. Transporter Acknowledgment of Receipt of Materials Transporter 1 Printed/Typed Name Signature Month Day Year O 113 - ca e Transporter 2 Printed/Typed Name Signature Month Day Year 18. Discrepancy 18a. Discrepancy Indication Space ❑ Quantity ❑Type ❑Residue ❑Par ial Rejection ❑Full Rejection Manifest Reference Number: 18b. Alternate Facility Generator) (or U.S. EPA ID Number J U Facility's Phone: w 18c. Signature of Alternate Facility (or Generator) Month Day Year Q Z 5, 19. Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste treatment, disposal, and recycling systems) ® 1. 2. 3. 4. 20. Designated Facility Owner or Operator: Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a Printed/Typed Name Signature Month Day Year cr,r,rur11ao1vu-2-CtRev.3-091 Previous edWonsare obsolete.