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V <br /> Please print or type.(Form designed for use al elite(12-pitch)typewriter.) Form Approved.OMB No.2050-0039 <br /> UNIFORM HAZARDOUS 1.Generator ID Number 2 Page 1 of 3.Emergency Response Phone 14.Manifest ' <br /> Number <br /> WASTE MANIFEST 0002884M 008824010 FLE <br /> 5.Generator's Name and Mailing Address Generator's ite Address(if different than mailing address) AM TO BICAIT SSE <br /> an W1b 11M OF ALL HAZARDOUS <br /> 515 s AA 96QA6 Y �l ATOMU BILLS AT LK <br /> Generators Pn«se 848 M SO TAB MSL STICK W T <br /> re`j Pony � U.S.EPA ID Number ��a CLANKM `9 <br /> 7.Transporter 2 Company NaRe\� � (\� � U.S.EPA ID Number <br /> � <br /> 8 Desgnaled Facility Name and Site Address U.S.EPA ID Number <br /> Tf0�66UUM <br /> N"law" <br /> 9a. 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit <br /> HM and Packing Group(if any)) 13.Waste Codes <br /> No. Type Quantity V"01. <br /> 1 <br /> DF p 0001931 <br /> Z 2 <br /> W <br /> 3 <br /> 4 <br /> 14.Speaal Handling Instructions and Additional Informal NkM#W Bid OwWrAlt D1010lBi <br /> 1) c�r►o�ooe 1 /X !S zs� <br /> 1 5 O L4 t o <br /> 15. GENERATOR'SIOFFEROR'S CERTIFICATION: I hereby dedere that the contents of this consignment are fully and accurately described above by the proper shipping name,and are classified,packaged, <br /> mFrked "Jed ed,and are in all respects in proper condition for transport aooadi g to applicable intemational and national governmental regulations.C export shipment and I am the Primary <br /> Ece ' t the contents of this cons gnment conform to the lams of the attached EPAAckrhowledgment ofIt ste minima statement identified in 40 CFR 262.27(a)(if 1 am a large quantity generator (if I am I )a true. <br /> Herat nn mea y ear <br /> x /V . /2 / <br /> J 16.IntematicFal Shipmen <br /> ❑Import to U.S. ❑Export from U S Pon of entrytexit: <br /> Transporter signature for exports on : Date leavirg U.S.: <br /> 17 Transporter Acknowledgment of Receipt of Materials <br /> Transportor,l`PnntedrTyped tine ` �-- Signature ay ear <br /> Q Transporter 2 Printed/Typed Name signature Month Day HCl <br /> IX <br /> 18,Discrepan <br /> 18a Discrepancy Indication Space Quantity ❑Type ^,❑Residue ❑Partial Rejection ❑Full Rejection <br /> t Reference Number: <br /> 18b.Atemate Facility(or Generator) U.S.EPA ID Number <br /> J <br /> LL Facility's Phone: <br /> W 18c Signature of Alternate Facility(or Generator) Month Day Year <br /> Q <br /> z <br /> 19.Hazardous Waste Report Management Method Codes(i a.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> us 1. � 2. A 4. <br /> —C <br /> 20.Designated Facility Owner or Operator:Certification d receipt of hazardous materials covered by the manifest 911pt as noted n Item 18a <br /> Printed? me y, <br /> e Vr�EPA Form 817(122(Rev. 5) Previous editions are obsolete. DESIGNATED FACILITY TO DESTINATION STATE(IF REQUIRED) <br />