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Please 1:16tif or ty(?et{I Orrin do ned{or use on allt�Ic. lypowiiei1. Form rAfapiouet;ONI®No.2051)-0039 <br /> F11A <br /> ARpf7lJa• 't,Cnt arnlar ID Number $,Pnge.i'nf 3.rwrpelrcy Raspp�aW�ort� ^� Wiest Tracking NUmbor <br /> iFE � CAR ®� ��® t��NNiiJJ 44 n S R q i.3 <br /> nn A s i Adf 65 if dl roll th t N ti ddrnes <br /> G. 1 R �� <br /> 112®, . T 00ROW <br /> STOC �8; 95 05 STOCKT 9 205 <br /> 000r..Irarnr's PlIcne: i j 1 ' <br /> G.7?:5n pxrinr t Comps y Wanae. 11.5;E A ID Numb,r <br /> .I WK 435 64. t42 <br /> 7.1+MTpn lar 2 Coryr nn Natise US''.EFA M:Numbw <br /> ' <br /> NM M 3V <br /> 133 <br /> i+.D+siSlnal41.r Facility Name and wllaAddr sw USECOLOGY' INC U.S.EPA ID Number <br /> f ac111�z Phone: ) -2"3 <br /> 9a, 9b.U.S,DOT Description(including Proper Sh)pping Name,hazard Class,ID Number, 10,Containers .Unit 11.Total 12 <br /> HM and Pang Group(If any)) No. type Quantity 2,un 13.Waste Codes <br /> t. P :� �6 001 Mf�8 a <br /> eel OF DOW P <br /> ,MIN,ERG 0171 DOW 101 <br /> 3. UN31 III,V1 <br /> 001 DM awl P ' <br /> ).&J.PON, OSM <br /> DW <br /> I- <br /> 4. <br /> 1 <br /> 4. 1i OF P 1 1 <br /> {__.._.,_..l_ <br /> f 1 <br /> 2.l4FMIM/8R dr"BLILM �. JjFftM1MjW44ESjyMFRE IS TIERS5 4 HMMMON <br /> HAZARDOUS UM11I <br /> 15, GENSIATOR'SfDFFERORIS CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by the proper shipping name,atxl are classlfed,packaged, <br /> marked and Sabaladlplacarded,and are in all respects In proper condition fortransport according to applicable International and national governmental regulations.If expert shlpmanl and I am the primary <br /> Exports,I cenify that the contents of this consignment conform to the terms of the attached EPAAcknowiedgmnt of CensanL <br /> I certify toat the waste mhlmlzallon statement IdentIfI0 In 40 CF 282.27{a)Oft am a large quantitygenerator)ar(b)(Ill am a small quanNy generalc is true. <br /> ,R,Iperatcf 9ff9oror r' rlritadlfype ' amp nalurd• �r 4ohi Uxy Yung$ <br /> W_ p _ - 49 f� rte• 1 a s'` .. �` <br /> 3 n emalianal-shipments <br /> ❑importto U. _S. ❑Expert from U.S. Poriof enlrylaxll: <br /> Transporter signature(for exports only): Data leaving U.S.: <br /> 17.Transporter Acknowledgment of Receipt of Materials <br /> E2 Tina;miter 1 0111 Nlffyped Flame SI ntlturF <br /> g i rvtunHt Da Year <br /> 9 1.7 <br /> y <br /> r o' lrinlodff !, a Stg a t4i001) [lay Ypar <br /> 18.Discrepancy t�—t <br /> 180.Discrepancy Indication Space ❑ t]uamtiy ❑type ❑Residue <br /> ❑Partial Re)eCllon ❑Full Ra)ecllan <br /> 18b.Alternate Facility Manifest Reference Number.lar Generator) U.S,EPA ID Number <br /> U <br /> Faelllty-s Phone: <br /> i8c,i gnaluro of lornele Fadf ty(or Generator) Month Day Year <br /> 5 19.Hazardous Wasla Report Management Method Codes(i.e„codes for hazardous waste treatment,disposal,and recycling systems) <br /> LU <br /> 01. H11 2 2 3 11 4 9 <br /> 20.Designated Facillty Owner or Operator CartIfIc8tlon of receipt of hazardous materials covered by the manifest except as oted in Ham 18a <br /> nrnl?t117,—W75—m—' ig{lplgre rr Month Onv ear <br /> r-ann[3700 2{I7ay.a p5}. flvfaus editions arerSl3aolato <br /> DESIGNATED FAC]L@TY TO DESTMA TMM 5y;ATE(IF REQU ET,,y <br />