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06/ 22 / 00 12116AM HPFAX Page 12IF ' <br /> t „ t MAR 019 <br /> IF IF + <br /> Please print or type. (Form des1 ned for use on elite (12-p)tch) typewriter,)- . Form A loved, OMS No, 2050,0038 <br /> UNIF=ORM HAZARDOUS 1 • Generator ID NumberIF <br /> I 2. Page t of 3. ErnergarlGy Respcgse Ptwnp 4; n(fes acjc. N [[�� <br /> WASTE MANIFEST e � i7 <br /> r fez `, �. SK <br /> 5. GsneratoPs Nama and#dafi ng Address Generator's S@e Address (it diffarant than ma tng a ress) <br /> Generator's Phone: <br /> 6• Transporter 1 Company Nanta U.S. EPA ID Number <br /> . . <br /> T Transporter 2 Cmripany Name <br /> U.S. EPAi Number <br /> 8. Designated Faullty Name and Site Address U.S. EPA ID Number <br /> FF+ IF F <br /> Faali4 IF IF <br /> sPhone' ; 4 11; .,. IF <br /> ga• 9b. U.S. DOT Description (induding Proper Shipping Name, Hazard Class, 10 Number; to. Containers Urtit 11. Total 12. 4 <br /> HM and Packing Group (it any)) No. Type Quantity 12, Ur L 13, Waste Codes <br /> f . A; <br /> IF <br /> ^.t <br /> IF IF <br /> 2. . ..a.., :. . <br /> �. + .. <br /> (� .. _ . . . <br /> + IF - . i. <br /> IFFA <br /> IFI <br /> 3. <br /> 4 <br /> 1 <br /> 4 _ l <br /> i <br /> 14. Special Handling Instrbctions and Additional nformation ) i <br /> . . . I I. <br /> t . IF 7 <br /> k , IF <br /> 16GENE and a OF EROR'S CERTIFICATION: I herebydeclare that the urdents of this consignment are full and accurately described above by the proper shipping name, are c • , , 1 .` <br /> " . s :.. . . , . . <br /> g Y assi0ed, packaged, <br /> pWCarded, and are in all respects in proper condillon for Iranspod according b applicable international and national governmental regulations , it export shipment and I am the Primary <br /> Exporter; i certify that the contents of this consignment conform to the terms of ilia attached EPAAcknoVixigment of Consent. <br /> I certify that the waste miniml ation statement identified in 40 CFR 262.27(x) Of I am a large quantity generator) or (b) (ill am a small quantity generator) is true, <br /> tor' <br /> GeneraslOtferof1 Prfntadlfyped Noma Signature Month Day Year <br /> ..t i6. Intamat enol ShipmentsMIMI <br /> P- ❑ import 10 U.S. ❑ Expert from U.S. Poi of entry/exit <br /> Transportor signature (for exports only): Date !saving U.S.; - -• — _ ..._ _._� ._— <br /> t9, TmnspkxterxhtNgnhent of Rece pt of Materials <br /> Transporter 1 PriMadRyped Namo SignatureMonth Day Year <br /> IF <br /> rn <br /> Transporar2 Pr ntedlTyped Namasignature Month Day Year <br /> I IF <br /> t8. Disaepancy nn <br /> 18x. Discrepancy Indkatbn Space Qirenttiiy O Type Residue Partial Rejection Full Rejection <br /> Manifest Reference Numbet: <br /> 18b, Nlemate Faciiily (or Generator) U.S. EPA ID Numbar <br /> C)' <br /> Fadkty`s Phone: 4 <br /> 18c. Signature of Nlamata Facility (or Generalor) Month Day Year <br /> d , <br /> a <br /> 19. Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste treatment, disposal, and recycling systems) <br /> p J . 2. 13, IF I IF 77� <br /> 20, Designated Fatty Owner or Operator; Certification of receipt of hazardous materials revered by the manifest except as toted In Item 18a <br /> Print yped Name Signature Month Day Year <br /> EPA Form 87(10-22, (Rev, 3.05) Previous edition's ar. .11 1 71 xENERATOFt 'S INITIAL COPY <br />