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Please print or type.(Form designed for use on elite(12-pitch)typewriter.) Form Approved.OMB No.2050-0039 <br /> UNIFORM HAZARDOUS 1.Generator ID Number 2.Page 1 of 3.Emergency Response Phone 4.Ma�Ife�Tr�cld jnm r� <br /> WASTE MANIFEST Twrm U CCJJ]]CCJJ771122 FLE <br /> 5.Generator's Nares and ailing Address Generators Silo Addreas lif different than ma}lirsg address) AFFIX TO RIGHT SIDE <br /> IMMUN �'���11�Eftidd(8je11�Fah) OF ALL HAZARDOUS <br /> Thmm TERIALS BILLS AT UNE <br /> 111 O TAR WILL STICK OUT <br /> Generators Phone: <br /> Grroas�porte�r CompanS.Company Name �qq U. EPA ID Number GXAW 1 <br /> ■ ,�::�vi•cM•. <br /> C11111111111111111111"T1111111111111111111i 111111113- (W � O <br /> 7 Transporter 2 Company Name U.S.EPA ID Number <br /> 8.DeslgnoW Facility Name and Site Address U.S.EPA ID Number <br /> bw <br /> no:Fadll11r1w B Btsf�!!y 1rf1I1�Dn1[laQE1 <br /> ga 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit 13.Waste Codes <br /> HM and Packing Group(if any)) No. Type Quantity Wt.Nol. <br /> ����� 1 OF YM, W <br /> 0 x - .99M <br /> z 2. <br /> W <br /> C7 <br /> 3. <br /> 4 <br /> i <br /> IA,Spociol Handling lnslructlnns and AddlWnal Informalion plod Nl1W 113go <br /> 1)NIMY ; I I q-I G- 617"_ . <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 international and national governmental regulations.If export shipment and I am the Primary <br /> Exporter,I certify that the contents of this consignment conform to the terms of the attached EPAAcknowledgment of Consent. <br /> I ce ty that the waste minimizatiRn statement identified in 40 CFR 262.27(x)Ilf I am a large quantity generator)or(b)(111 am a small quantity generator)ds true. <br /> @HerarG n ypec na re nn a rear <br /> �i r`f �� A - <br /> 16.11iintemational Shipments <br /> 1= ❑Import to U.S. ❑Export from U.S. Port of gtrylexlt <br /> Transporter signature for B ds only): Dale IeaV sl U.S.: <br /> W 17.Transporter Acknowledgment of Receipt of aterlals <br /> 0-1m <br /> r'l ri <br /> Nam <br /> O <br /> a <br /> � Month a Year <br /> 0- Transporter 2 Printedl'fyped Maine Signature Y <br /> H <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space Quantity ❑Type ❑Residue ❑Partial Rejection ❑Full Rejection <br /> Manifest Reference Number: <br /> 18b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> J_ <br /> rJ <br /> LL Faralll'S Plmne: <br /> W 1 ft,Signature a Alt male Facility or Generalarj Month Day Year <br /> Q <br /> Z <br /> 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> we 1 7., 3. 4. <br /> 20. Wed Facliiiy Owner or Operator:Certification offhelvl of hazardous materials covered by the manifest except as noted in Item 18a <br /> Prinled mo Sign Month ay Year <br /> EPA Form 87 0 2( v. 5) previous editions are obsolete. DF SIN ATED FACILITY TO DESTINATION STATE(IF REQUIRED) <br />