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c- rn <br /> � <br /> N W <br /> Q U3 <br /> o 7 <br /> D Please prrnl or type. <br /> DUNIFORM HAZARDOUS l Generator Ip rvum¢r Form Approved.0M6 N.2050 0039 (") <br /> WA57E MANIFESF �'mel of 3.Emerg n�y tiespp� a Phone TEPAIIIA—bel <br /> Trazking Number N <br /> z s <br /> G". r— l—F10rp--[yr-',pj—f7FlnZ <br /> u;oimv An,{rc�c 007439- 3, CD <br /> Geoeramrs Site Address W di9erem man essl <br /> _ .'.�.... it f O <br /> W Generamr's.most D <br /> 6.7rensfdter,Ce,npanl la,x,.r ! L.. NUmher <br /> Transrwae!:�.a.mnanl'Nan„ <br /> FIPr 4ARr D Number6-Designated F-rdp Name stria:&And'fsi1ID NumberWPhoneest ?b.US DOTDei1VI r•,u,c!.a11ng Proper Shipprng Nama,Hazard Class,In Number, t0.Containers HAI and PainQ Gmop til�r•..':• 12,Unit 1No. Type WI.Not. <br /> p tel11% <br /> r– <br /> a J <br /> WCD <br /> i <br /> cru ! <br /> J "Ilk <br /> 3 � <br /> Sl ial Handling instruc@ons and Additional Information <br /> ,;v+4 17 CSCss <br /> ?4N FMcF: rol'ail l beneratrer eanfers a envy act <br /> r <br /> 15 GENEPATOR'SIQFFEROR'S CERTIFICATION_ I hereby declare[bat the contents of this consignment are fuily and accurately described above by the proper shipping name,and are classified,paekagec. <br /> marked and labeled;placarded,and are in all respects in proper condition for transport according to applicable international and national governmental regulations.If expert shipment and I am the Primary <br /> Exporter,I POW that the coarents of this consignment conform to the terms of the attached EPA Acknowledgment of Consent. .. <br /> I certify thaf"i minimization sI Iemenl identified in 40 CFR 262,27(.)iif I am a large quanlil........... <br /> or small quantity gbn'eatvr}is true. <br /> Genera roffews pnoj.5padName Signature f Month Day Year <br /> 1 76.international Shipments <br /> ❑import to US. ❑Export from U.S. Pod of entryierii <br /> Z Transpoder signature(tor exports only), Date leaving U.S.'. <br /> IT Transport t rAcknowledgmenr of Receipt of Mall <br /> i <br /> ns r I Printed.?yped Name Signature Month Day Year <br /> s <br /> 7ranspoAer 2 Printed;7yped Name Signature Month Day Year <br /> 18 Discrepancy <br /> lial Discrepancy tndiration Space <br /> ❑OuanGly ❑Type Ll Residue ❑Partial Rejection ❑FUIIAejeclion <br /> Manifest Reference Numbur <br /> b Aternate Facility(or Generator) U.S.EPA ID Number <br /> Ilify's Phone <br /> Signature ofAl#ernate Facihly(or Generator) Month Day Year <br /> CD <br /> y4"ous Waste Report Management Method Codes(i e..Codes for hazardous waste Instalment,disposal,and recycling systems) t O O <br /> 2. 3. v <br /> haled Facility Owner ar Operator:Codification Cif receip#of hazardous materials covered by the manifest except as noted in Item 1 Be <_ <br /> rAn flame 5ignalure Month bay Year <br /> O <br /> (D Fpft.�(Rev. 12.17) Previous editions are obsolete. GENERATOR'S INITIAL COPY 00 <br /> cn :I;aigr . '1�� 'r��r O <br /> O <br /> Q0 <br />