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C— b W W <br /> rn O W v <br /> O _ IV CY) <br /> O O <br /> G) <br /> _ PQo <br /> v <br /> v <br /> Please print or type.(Form designed for use on elite(12-pilchl typewriter.) Form Approved,OMB No.2050.0039 00 r <br /> 1.G nerafmr tO Number 2 P e 1 of 3,Eme enc Res nse Phone 4.Manifest Tracking Number <br /> _ _ } UNIFORM HAZARDOUS � a9 � Y p° g �( <br /> rll Ir WASTE MANIFEST C^.� rl rips p rhr,,{�q.y,.'.fr!:' ` k1` O O <br /> W 5 Central..sN t--not hlartinq f{dd. ss Genar I ra Silenddress lifditferent than mailing addre<sl VV 4,4 -p- Q <br /> Generators Phone: <br /> 6 Transmrfer-1.Cwnhy Nanit: UT EPA Ip Number ✓V <br /> 1.Tran WCsm'uter2Ft4�C3 nl y,r c <br /> US EPA ID N—rm ,, C <br /> 60es a(,gdFaeiliN lvam�:;3n;I5ile Audrz;; U.S,EPAIDN—ter <br /> CD <br /> •un�A c_ �+�{IveyrtF <br /> Facility's Phone: . <br /> 9a ad.U iog-S DOT Deacoph-jrnducProper Shipprng Name.iClass.ID Number. 10.Containers 11.Talal 12.'1 <br /> NM and Packing Group i f anylI No. Type Duantity Wt.Nol, 13.Waste Codes <br /> 1 O <br /> K <br /> O � <br /> 4 <br /> UpfY <br /> Up <br /> 0 H <br /> 3 <br /> (7 <br /> O <br /> 4. <br /> l'7 <br /> 14.Special Handling Instructions and Additional Information t• <br /> EMERGENCY CONTACT cwurli 1-800.424.9300 eY "I?OF11 f a'-I81 C) <br /> n <br /> 16MMIRS)IF761 PAPER FILMRS" *APPROPRIATE PPE EQOiPMEN7 <br /> Q.. <br /> 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.aware classil packaged, <br /> marked and labeledfpli and are in all respects in proper candition for transport acoordtag to applicable international and national gevernmenlal regulations.if export shipment and I am the Primary <br /> Exporler.1 certify that the corn is of this consignment conform to the terms of the attached EPA Acknowledgment of Consent. <br /> r+ <br /> I ceb}y That the waste minimization statement identified in 40 CFR 262.27(a)(i(I am a large quantity generator}0((b)(d I am a small quantly generator)is true. � <br /> GPWatofsfDeeror's PdntedRyped Name Signature Month Day Year <br /> J Id.International Shipments <br /> ❑Import to U.S. ❑Export from U.S. Port of enlrytexit: _ <br /> Transpoder signature(for exports only): <br /> Date leaving U.S.: <br /> w <br /> 17 Traruxporter Acirn*wgmenl of Roceipl of Matenals <br /> j Transporter 1 Prnded(Ii Name Signature Month Day Year <br /> 4 <br /> d <br /> = Transporter2 PnntedyTyped Na a Signature Month Day Year <br /> 4 <br /> H <br /> td.Discrepancy <br /> 18a.Discrepancy Indication Space ❑Ouantiy ❑Type ❑Residue ❑Partial Rejection ❑Full Rejection <br /> Manifest Reference Numbec <br /> fab.Allampba Faddy(or Generator) U.S.EPA ID Number <br /> _J <br /> t.1 <br /> LL FaEI( E Rune. <br /> W SBe Signature ofA)Wnale Facility for C.eneraWr) Month Day Year <br /> 4 <br /> ) Y <br /> 19 Hail Well Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal.and recyulin)systems) <br /> 4 O (D <br /> (Q n <br /> � O <br /> v Q <br /> or 4perafor Cgirdeadon of recti of hazardous materials covered by IN manifest excepl as noted in stern 10a <br /> Signaluee Month Day Year <br /> C_ <br /> ILI <br /> hilib ns are obsolete GENERATOR'S INITIAL COPY CD <br /> 0 <br /> v � <br /> � w <br /> m 00 <br /> 0 <br /> O <br /> IV <br />