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Please pr.t type (Farm designed for use on elite(12-pitch)typewriter.) Foran Approved.OMB No.2050-0039 <br /> UNIFORM HAZARDOUS 1.Generator ID Number 2.Page 1 of 3.Emergency Response Phone 4.Manifest Tracking hu <br /> JJ K_ <br /> F1WASTE MANIFEST J v <br /> 5 Name and Mailing Address Generator's Site Address(if different than ma ling address) <br /> Phone, <br /> 6 Tra s4T 1 Company Name U.S EPA ID Number <br /> ? Tra�scc-er 2 Company Name U.S.EPA ID Number <br /> 8 Da,,g7 Facility Name and Site Address U S.EPA ID Number <br /> F3.: ^e <br /> 9a %t-J S DOT Description{including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit <br /> Hh1 any));Packing Group(if an13.Waste Codes <br /> - No. Type Quantity Wt.Nol. <br /> r <br /> O <br /> r— <br /> w <br /> z <br /> w <br /> O <br /> d <br /> 14 Spec a' 3ndhgg Instructions and Additiottal Information <br /> 1 14111Rd <br /> a w-At it+l(rttr <br /> ' = t. -Il #(x'#'7%6 1 i .k tw <br /> 15 GENEPAATOR'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 /> m 3r cv and labeled/placarded,and are in all respects in proper condition for transport according to applicable Intemational and national governmental regulations.It export shipment and I am the Primary <br /> Expo-'- I certify that the contents of this consignment conform to the terms of the attached EPAAcknowledgment of Consent. <br /> I c en-fy that the waste minimization statement identified in 40 CFR 282.27(a)(KI am a large quantity generator)or{b)(4I am a small quantity generator)is true. <br /> Generators,Offemrs Printad'Typed Name Signature Month Day Year <br /> j 16 intern, <br /> t -3l Shipments <br /> Z ❑Import to U.S. ❑Export from U.S. Port of entrylexft: <br /> Transp_mer c grnature(for exports only): Hate leaving U.S.: <br /> W 17 Trar_pc'e,Acknowledgment ofReceipt ofMaterials <br /> Transperier^PrintedfTyped Name Signature Month Day Year <br /> O <br /> It. <br /> U) <br /> ZQ Transp[ter PnntedfTyped Name Signature Month Day Year <br /> H <br /> 18 Disceoa^..r <br /> 18a Ciscrep3rcy Indication Space ❑ Quantity ❑Type. ❑Residue ❑Partial Rejection ❑Full Rejection <br /> Manifest Reference Number. <br /> 18b AlterraL Facd ry(or Generator) U.S.EPA ID Number <br /> J <br /> U <br /> LL Facility's Pho-e <br /> w 18c Signature of Alternate Facility(or Generator) Month Day Year <br /> a <br /> z <br /> O 19.Hazarc,;,;Waste Repan Management Method Codes(i.e.,codes for hazardous waste treatment disposal,and recycling systems) <br /> t r 3 4. <br /> 20 De :^atec Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a <br /> Pnn[ed T,rF name Sgnalure Mantle Day Year <br /> EPA Form 870042(Rev 3-051 Previous editions are obsolete. GENERATOR'S INITIAL COPY <br />