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Please print or type. (Form designed for use on elite (1 2-ndrhl hT~Mpr I <br />DESIGNATED FACILITYTO GENERATOR <br />A, <br />V <br />...... I P"ruveo. VML1 F40. ZUNAWV <br />1. Generator 77 E .. <br />UNIFORM HAZARDOUS ID R7� 0��7 M@nNW Trackl�!Niumber <br />z"i`7 In <br />-T <br />WASTE MANIFEST <br />"""*32891r- SK <br />5. Cienerators Nam and Mailing Address Generators Site Address (d Merent than mai" address) <br />sc'oits AVP <br />ME TON <br />G,w,t,e, Phone: <br />6. TN <br />IN S' U.S. EPA ID Number <br />7. Transporter 2 Company Name U.S. EPA ID Number <br />(AZ 0 C 3 <br />8. Designated Facility Nam and Site Ad&M CLEAN HARBORS LA P'MRITE LLG U.S. EPA ID Number <br />500 INDEPENDENCE PAMK' Y SWH <br />I,l� F'ORTE TX 77571 <br />Facit (s Phone: I <br />ga. <br />9b. U.S. DOT Description (incluftg Proper Shipping Name, Hazard Class, ID Number, <br />10. Containers <br />11. Total <br />11 Unit <br />HM <br />and Padung DWI) (d -Y)) <br />Ouantity <br />WL1Vo1. <br />13. Wavle Codes <br />No. <br />Type <br />NON RCRA iini 1F, 77,77 IT, <br />')9 ) 4 P F T F ICA' I D P R 13 F N <br />ENO <br />DOTS <br />4 QW I <br />2. <br />UJI <br />3. <br />4. <br />74. Special HV4kV Instructions and Additional himmation <br />6,71 CV7 0 <br />1�y LC -N 10 P�ii- &L"�" <br />15. GENERATORMWERWSCERTIFICATM: I hereby declare that the Contents Of"" consignment are 6* and accurately described above by the propershippN name, and are dessilled, pa&s*, <br />marked and labeledUplacarded, and are in an respects in proper condition for "MW according 10 SWIG de international and national governmental regulatiorts. 0 export shipment w4 1 am the Primary <br />EV&W, I ON* that the owdents of this corWpment <br />conform 10 the terms of the attached EPAAdmo*Wrwd of ConsenL <br />— I certify that the waste minirni73bon statement idended in 40 CFR 262.27(a) (d I am a large quantity generator) or (b) (dl am a small quantity generator) is true. <br />si011erces PmA967TWN" Signature Month Day Yew <br />er 19-1 -; r C <br />16. h*maWW Sipments ( <br />h <br />1:1 I.Pd to U.S. El Export from U.S. Port <br />Of entry/ext: <br />Transporter signature (for exports only): Date leaving U.S.: <br />17. Tra%porler Adw&Wgment of Receipt of Materials <br />Tra" <br />1 ftWTyW Signature MorM D" Yew <br />1.167 J -rI <br />1 2. rZ 1;A <br />-WPM— X''r moo my Yew <br />, -- -- .0 <br />is. Di6areparxi — <br />18a. Discreparoindicabon Spam 1:1 Quantity ❑ Type ❑ Residue ❑ Partial Rejection E]Fhb Rejection <br />Reference N~. <br />48b. Alternate Faddy (a Generator) U.S. <br />U.S. EPA ID Number <br />LA. <br />FwWs Phone: <br />18C. Signature o(Allernalle Facility'(gr Month <br />Oay YM <br />[19. <br />Hazardous Waste Report Management Method Codes (i.e., codes for hazardobs waste treatment, disposal, and recycling systems) <br />3. <br />T <br />20. Designated Facility Oww or Operator Certification of receipt of hazardous materials covered by the mardw as noted in hem 18a <br />lyped Name f SlgnakA* Year <br />I �' ('1— <br />;PA <br />�/� <br />Feirm R7nn-" IR— 'LMI P—AQ.. <br />DESIGNATED FACILITYTO GENERATOR <br />A, <br />V <br />