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L :v 1 . eIt W W <br /> N <br /> N <br /> O 1ar0 N 67 <br /> Please prim cr rype.(Form designed for use on elite 112-ildi Uap�Q O <br /> P llypewnler.) <br /> UNIFORM HAZARDOUS 1 Gerreator 10 Numher Form Approved_0M$No.2056-W38 * G r N O <br /> 2.Rage 1 0! 3.Emeymcy faeaaonse phone e.Man"rfeat TracXing Number <br /> OJ <br /> WASTE MANIFEST 1 11/ <br /> �' S. �f _ \'me.and hlyl,no less !��� - JJK <br /> E - �,yieralGry i;e 0.ddn'?s;nl^iH4,=nl <br /> a,rr,g addreri DO (— <br /> �. <br /> T.-porter, <br /> Phone' IW—� <br /> 6.Tranepprter 1 Cnrgpany Name IV Q <br /> Wi iHl F1(xiL F Mi`:" U 7i EPA ID Numbar <br /> 7 Transpener 2 G mpany Mame <br /> D S.EPA ID rvember <br /> 8 Desfgol Fanidy Name antl 9r� <br /> F P4AftA4 -- NS.EPA ID Numher <br /> Fades s Cn <br /> Phore: <br /> ga, 9b.LIS DDT Der.:n:��; �..n,i P aper shipping Name.Hazard Class iD Number, 16 Gonymer, <br /> NM ar.�l Far'xina[.riot.,i i�r-.i� 11 Total 12.Unit (P <br /> No. Type Cuanury wl.Nol. 13.Wasu Cadea <br /> O , <br /> C7 Q <br /> 3. <br /> 4. Uj <br /> 14 Spetnlnrmatior, Q„ <br /> , Q <br /> 15. GENERATOR'SfDFFEROR'S CERTIFICATION I hereby dedare that the eonlents of this consignment are fully and accurately described above by the proper shipping name,and aw classified,packaged, ('� <br /> marked and labeledlplacerded,and are in at respects in proper condition for transport according to applicable inlemational and national governmental regulations.if export ships land!am. Pdmary Q <br /> Exporter.I cerply that the contents of this onsgnmenl onion to the terms of the ahairl EPAAcknowledgment of Consent. I' <br /> I certify thal the waste minimization statement identified in 40 CFR 26227(a)(if I am a large quantity generalor)or(b)tiff am a small quantity generator)is true. <br /> Ganeratorsi0fremrs Prinledffyped Name Signature Month Day Year e�-F <br /> I <br /> J 16.intemalional Shipments <br /> 2 ❑Import to U.S. ❑Export from U.S. Pori of enhylexit', Q <br /> Transporter signature(for exports onlyy. Date leaving U.S.: <br /> old 17.TransporlerAcknovAedgmenl of Receipt of Materials <br /> Transporter 1 Printed(Typed Name Signature Month Day Year e--r <br /> O � <br /> a <br /> Transporter 2 Pnnled7yrrd Name Signature Mol Day Year {' <br /> a Discrepil <br /> 18a Orscrepaney Indirrahen Spare. ❑Ouaniity ❑Type ❑Residue ❑PaNal Rejection ❑Full Rejection <br /> Manifest Reference Number: <br /> 18b.Aherno Facility for Genereort U, <br /> lS-EPA ID Number <br /> _J <br /> L.1 <br /> W FaroWs Phone. <br /> W Mile.SOletiae idAllemale Facill jar Generator) Month Day Year <br /> H <br /> 19.KPZN&m Waste Report Management Mehl Codes ke..Codes for hazardous waste treatment,disposal,and racycting systems) <br /> 1. 2 3 a. ► <br /> FatlrF 0.or Opera3or Cerpficah'on of rarafpt old hazardous materials covered by the manifest except as noted in Item 18a <br /> SignatureMonth Day Year <br /> 3-06)Previous ed+LlDn6 are oh5olele. GENERATOR'S INITIAL COPY p (D <br /> (Q n <br /> O <br /> v Q <br /> .(l <br /> O <br /> Uri <br /> v � <br /> LQ W <br /> CD W <br /> O <br /> N CYI <br /> O <br /> N <br />