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Form Approved.OMB No.2050.0039 <br /> Please print or type � ,r, . � : +�. „. �,� PP <br /> "' 1.Generator ID Number 2;Page 1 of 3.Emergency Response Phone- (' 4.Manifest Tracking Number r t <br /> UNIFORM WASTE MANIFEST �,AI. w-)e ! -5 44-4"",j P"T .t' 9 4 tJ J K <br /> 5.Generator's Name and Mailing Addressf� Gen"erator's SlteAddress'(if different than mailing address) <br /> Generali es Phone: <br /> 6.Transporter l Company,Name, <br /> .� d iU S EPAIDNumber <br /> 7 Tr nsporter 2 CompWhy Name U.S.EPA ID Number <br /> 8.Designated Facility Name and Site Address etJ " U.S.EPA ID Number <br /> cility Phone: <br /> 9a. 9b.U.S,bOT Descrlpgon(including Proper'Sl ipping Name';'Na, ed-Class ID Numfier 10.`Contamersi`. a`�1 Tptal ''' `12 UmP <br /> and Packing Group if an "' '` �`''QuantiiNCNoI.' 13.Waste Codes <br /> HM 9 Pl y)) No "TYpe t! <br /> O •,v, k.• :� .:� i' �� 'f�G'.7` G+ tfr+J�C.r' 'c�1�4+' '`. _ „'r ., .Y'aJi.:, <br /> w 2' <br /> 3. <br /> 4. <br /> 14.Special Handling Instructions and Additional Information <br /> r <br /> VV S <br /> 61 <br /> tV..r/� ' <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,and are classified,packaged, <br /> marked and labeled/placarded,and are In all respects in proper condition for transport according to applicable/nternationaland national govemmental-regulations..if export shipment and I am the Primary <br /> Exporter,l certify that the contents of this consignment conform to the terms of the attached EPAAoknowiedgment of Consent. <br /> I certify that the waste minimization statement identified in,40 CFR 262,27(a)(if I am a large quantitygenerator)or(b)(ifI am a small quantity generator)is true. <br /> GeneratoeslOfferor's PdntedlTyped Name Siglature Month Day Year <br /> _j 116.International Shipments~ <br /> i--, ❑Import to U.S. ❑Export from U.S. Port of entry/exit: <br /> ? Transporter signature(for exports only): Date leaving U.S,: <br /> W 17.Transporter Acknowledgment of Receipt of Materials <br /> 12 Transporter �rinted/Typed a Signature r Month Day Year <br /> a (le <br /> Tran porter 2 Printedrryped Name Signature V Month Day Year l <br /> l �r� •�^, r i; ��.' ��r,G ; a � �. I k) i ,��r , :� � <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space ❑Type ❑Residue �..1 jection Rejection <br /> ❑ Quantity ❑Partial Re ❑Full Re <br /> Manifest ReferenceNumber: <br /> H 18b.Atemate Facility(or,Generator) U,S:,EPA,ID Number <br /> J <br /> W Facility's Phone: <br /> W 18c.Signature of Altemate Facility(or Generator) Month Day. .,Year: <br /> a <br /> z <br /> 2 19.Hazardous Waste Report Management Method Codes(Lei.,codes for hazardous waste treatment,disposal,6Hd recycling systems) �?)� <br /> —T2, 3. 4. <br /> Ca <br /> '20,Designated Facility Owner or OperatorrCertifibatiori of receipt of hazardous materials covered by the manifest except as noted In Item 18a <br /> Printedrfyped Name Signature Month Day,; Year <br /> EPA Fon--6700-22(Rev:'12-17) Previous editions are obsolete. TRANSPORTER COPY <br />