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Please print or We.(Form designed for use on elite(12 p typewriter: Form Approved.OMS No.2050-0039 <br /> I.Generator ID Number{ 2.Page 1 of 3.Emhergency Response Phone Man"Traektu g Number <br /> UNIFORM HAZARDOUS / j j Cr r^ r"f "07944595 JJK <br /> WASTE MANIFEST � `��„�,.� �:� <br /> S.q%wrator's Name 8"Th Addtass Genemlors Site Address(d different than mailing address) <br /> Vhf it° 7 r5 <br /> 76- <br /> .� <br /> Generators Phone: t l(t' t 1 y° t`Q �E. ( / <br /> 6.Transporter 1 Company Name U.S.EPA ID Number <br /> �.��._r• Y !C.` � .F t !o y:�3 ._...E...� ��P3 i..-6 f ♦'t.? trt� f� Y`��'�•+C.��� 1,..,,•• <br /> 7.Transporter 2 Cooi l@*Name U.S.FPA ID Number <br /> 8.Deshgnatsd Fach•Ny Nam and S7Address T lfj U.S.EPA ID Number <br /> h ,( t L <br /> Faality s Phone: s t. iAd ,.:.r`� t �,:' ?. _1` f '7 4 4. > rc <br /> 9& 9b.U.S.DOT Descrtptan,(ithdudmg Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit 13.Waste Codes <br /> HM and Padahg Group(d any)) No. Type Quantity WtNot. <br /> Vt l"t <br /> z 2: <br /> LU _ <br /> t9 <br /> 3. <br /> 4. <br /> 14: I Harg I atxi Wawa Information <br /> i.. Too <br /> 7Fz' <br /> 15. GENERATO[r ROR'S'CERTIFICATION:I hereby declare that the conterdof this conalgrutient are fully and accurately described above by the proper sh4#nb dame,aril are classified,padcaged, <br /> marked and labeledfplacarded,and are In all respecfs in proper condition for transport according to applicable international and national governmenial regulations.If export shipment and f am the Primary <br /> Exporter,I certify that the contents of this consignment conform to the terms of the attached EPAAdcnowledgment of Consent <br /> I certify that the waste minimization statement Idarttied In 40 CFR 2V-27(a)It I am a large quanttiy generator)or (di am a small quantity generator)is true. <br /> Generators/OfferorsPrintmUTypadName r c Signature Month Day Year <br /> ._.r 16,international Shipments , <br /> F. ❑import to U.S: a Export irwrh U S:` Port of enhylexit <br /> Transporter signature(for exports ordy): ' Date 1eaVirig U.S.: <br /> W 17.TransporterAdmawledgment of Receipt of Materials <br /> WTgnsporter 1 Pdrtt@dt yped'Name igttaptm r r Month Day Year <br /> QTransporter 2 Pdnted/fyped.Narhe Signature Mordh Day Year <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space Quentiy Type ❑Residue ❑Partial Re)ectah ❑WI►Rejection <br /> Manifest Reference Number: <br /> 1Bb.Alternate Facility(or Generator) U.S.EPA ID Number <br /> FacAlty's Phone: y .. <br /> Year <br /> 18e.Signature ofAltemate Facility(or Generator) Month Da <br /> Q <br /> Z ri3r,a <br /> 19.Hazardous Waste Report Management M ga(i.e.,codes for hazardous waste treabnent,disposal,and recycling systems) <br /> ® 1' 2 3. 4. <br /> 20.Designated Fsatity Owner or Operator.Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a <br /> PdntestTyped NahrreSignature Mordh Day eater <br /> EPA Foran 87DO-22(Rev.3.05) Previous editions are obsolete. GENERATOR'S INITIAL COPY <br />