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Please print of type.(Form designed for use on elite(12-pitch)typewriter.) Forth Approved.OMB No,2050-0039 <br /> UNIFORM HAZARDOUS 1.Generator ID Number 2 Page 1 of 3.Emergency Response Phone 4.Manifest Tracking Number <br /> WASTE MANIFEST L 4_1 .3 :1 u "►8 8 JJ K <br /> 5 Generators Name and Mailing Address Generator's Site Address(it different than mailing address) <br /> ei t 2041 Navy I). <br /> r A ')9206 <br /> Generators Phone: t A -Kill 79 <br /> 6 Transporter 1 Company Name U.S.EPA iD Number <br /> veer & stess <br /> Trh. prter 2 Company Name U.S.EPA ID Number <br /> 8 Desgna:ed Facility Name and Site Address U S.EPA ID Number <br /> f <br /> Facility's Phone: <br /> 9a 9t U.S.DOT Description(including Proper Shipping Name,Hazard Class ID Number, 10.Containers 11.Total 12.Unit <br /> HM acid Packing Group(If any)) 13.Waste Codes <br /> No, Type Quantity Wt1Vol, <br /> z 2. <br /> W <br /> i.7 <br /> 4 <br /> 14 5pe ai Handling Ynstructions and Additional Information <br /> rt <br /> flTrear PXDPer PPE Cloth,n+ — T cnntsc-t rKEZ=FC , <br /> G Regi s t:ant SM9197473A A MGt <br /> 15 GENERATOR'SlOFFEROWS CERTIFICATION:1 hefeby declare that the contents of this congnment are fully and accurately described above by the proper shipping name,and are classified,packaged, <br /> marked and labeled/placarded,and are in al respects in proper condition for transport according to applicable international and national governmental regulations.If export shipment and I am the Primary <br /> Expc r!er I certify that the contents of this consignment cmoriform to the terms of the attached EPAAcknowledgment of Consent. <br /> I certify that the waste minimization statement identified in 40 CFR 262.27(a)fd I am a large quantity generator)or(b)(d I am a small quanti generatnri is true. <br /> Generators Offerors Prin Lped Name Signature Murith Day Year <br /> J 16 International Shipments <br /> _i <br /> i ❑Impart to U.S. ❑Export from U.S. Port of entryle)it: <br /> Transporter signature(for exports only): Date leaving U.S.: <br /> 17.TranspcderAcknowledgmantofReceipt ofMaterials <br /> LU <br /> OTransporter 1 PnnledlTyped Name Signature Month Day Year <br /> 126 1 147 <br /> Q Transporter 2 PnntedlTyped Name S gnature Month Day Year <br /> IlY <br /> H <br /> 18.Discrepancy <br /> 18a.D screpancy Indication Space ❑ Quantity El Type ❑Residue Partial Rejection ❑Full Rejection <br /> Manifest Reference Number: <br /> 18b.Alternate Facility(orGeneralor) U.S EPA ID Number <br /> J <br /> V <br /> Facility's Phone <br /> Lut 18c.Signalure of Alemate Faclity(or Generator) Nicnth Day Year <br /> I— <br /> jh19 <br /> .Hazardous Waste Report Management McBrod Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> r <br /> 3 4. <br /> 20 Designated Facility Owner or Operator:Cerbfication of receipt of hazardous materials covered by the manifest except as noted in Item 18a <br /> PrintedT ped Name Signature Mcilh Day' eco <br /> EPA Farm 870x•22(Rev.3-G5) Previous editions are obsolete. DESIGNATED FACILITY TO GENERATOR <br />