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PleasePint ar <br /> p type.{Form designed far <br /> UNIFORM HAZARDOUS <br /> WASTE MANIFEST <br /> 1.Ge <br /> 5 Generators Name and Me ng Address <br /> BEILK-Orq 75 <br /> GenerafWPhone, ) <br /> 6,Transporter 1 Company Nurse U.S EPA ID Number <br /> 7.Transporter 2 Company Name <br /> U.S.EPA ID Number <br /> 8 t--Fated EpCfy gag a d S fejt fts <br /> U.S.EPA ID Number <br /> Fatx5tys Phone• <br /> ga, 9b.U.S.DOT Desc bOn(including Proper Shipping Name Hazard Class D Number 16.Containers <br /> HM and PaGumg Group(a any tat 12 Un: <br /> No. Typo O Sty Wt/W W <br /> O <br /> LU <br /> i <br /> w <br /> I <br /> 3 <br /> 4. <br /> 14.Special Handling Instructions and Additlonat Informwt m r - <br /> Use C!mss ti. f r 1i'1 ,ret e# ZI 3� <br /> 15. GENERATOR'S*FFEROR'S CERTIFICATION:I hereby declare that the contents of this consignment are fatly and a=rately desonbed above by the proper shipping name,end are classified,packaged, <br /> marked and fabs Woacarded,and Mir all res kin proper kxxhdition for dans acwrdl to a <br /> Exporter,I certify that the contents of tis n9 applicable International and national governmental regulations.If export shipment and I am the Primary <br /> consignment conform to the terms of the attached EPA Acknowledgment of Consent. <br /> that the waste_m�r`tmhfzatioon stetemerri fderiji ed In 40 CFR 262.27(x){f I am a large quantity generator or <br /> Genhhra� urs tedlT — —- 1 @}Of I am a smaq quantity generator}is true. <br /> �� �� 5ignatWre Z Month Day /Year <br /> -r 15.In t 5thlpment9 i <br /> ❑import to U.S. ❑Export from , . Port of entrylehdt <br /> Transporter signature(for exports only): <br /> 17.TransporterAdmowfedgment of Receipt of Materials Date leaving U.S.: <br /> Transporter I PdnMdlTyped Name <br /> 5lgnallh r Month Day Year <br /> Q Transporter2 PdnWayped Name -- <br /> SgnauMonth Day Year <br /> 18,Discrepancy <br /> i Ba.Discrepancy Indication,Space <br /> ❑ Ouanttly ❑Type ❑Residue ❑Partial Re{edlon ❑ <br /> Fufi Re)ecton <br /> ido.Alternate Fac'Tty(o Generator) Manifest Reference Number. <br /> US.EPA ID Number <br /> tai FaCiiity's Phoma: <br /> 18c ignature ofAltemate Facility(ar ener1-U --or) <br /> Z Month Day Year <br /> y19.Hazardous Waste Report Management Method Codes{f.e.,lodes for hazardous waste treatment,disposal.and recycling systems} <br /> W 1 titttW �..a ({{ 4 <br /> 29.Designated Faality Owner or Operator Certification of Moeipt of hazardous materials covered by the manifest except as noted In item 18x <br /> -rintec. yped Name <br /> t "Z gnature I Month Cay Year <br /> A l � � � h � , 1 . <br /> EPA Fom1870{)•22(Rev.3 05} Previous editi1 ons aro obsolete. <br /> f~ TRANSPORTER'S COPY <br />