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Please print or type.(Form designed for use nn elite(12-pitch)typewriter.) Form Approved.OMB No.2050-0039 <br /> UNIFORM HAZARDOUS 1 Generator ID Number 2.Page 1 of 3.Emergency Response one 14,Manifest Tracking Number <br /> -.. �r, .,: # t :.. ... , �a _: DAT <br /> WASTE MANIFEST k �f » Eve Vit' °"t, <br /> 5.Generator's Nance and MailingAddress p,.Mg_ xS i Generator's SileAddress(if different than mailing address) <br /> ;� �m*v uv <br /> Goneratoes Phone; <br /> 6.Transporter 1 Company Naive U,S-EPA ID Number <br /> fss��3'si1T'.s`t'EZ �,`��t:�`�,iBfrYi��ls.:•.=(;.��*��i it"'�`s�i�;°��fdEi�('.j`at.^�)S�&��tt g.4:"''t"" treF''�ai y� ,���<"�rd <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> e.Designated f=acility Name and Site Address U.S-EPA ID Number <br /> 104R"W"WAR11 <br /> Facility's Phone: s' - <br /> ga eb.U.S.DOT 0escripllpn(Including Proper Shipping Name,Hazard Class.ID Number, 1o.Containers 11.Total 12.Unit 13.Waste Codes <br /> HM and Packing Group(if any)) d t R No, Type quantity Wtivol. <br /> Z 2. i <br /> 3. <br /> 4, i <br /> 14.Special Handlicg Insimdtions and Additional Information <br /> 1jr�� - 'fI.?t�.€a xl _, ft. rte' <br /> i <br /> 15. GEN ERA€OR'SfOFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately desc6bed above by the proper shipping name,and are classified,packaged, <br /> marked and labelediplacarded,and are in all respects in proper condifon for transport according to applicable international and national governmental regulations.if export shipment and I am the Primary <br /> Exporter,I serfify that the contents of this consignmenl conform to the terns of the attached EPAAcknowledgmenl of Consent. __j <br /> I certify that the waste m4rimizat on statement identified in 40 CFR 262.27(a)(if I am a large quantity generator)or(b)(if I am a small quantity generator)"islrue. <br /> Generator sl0ffemr's PrintadiTyped Name Signature Month Day Year <br /> —r 16:iniemational Shipments ) [ f <br /> P- ❑Import to U.S. ❑aped from U.S. (Poftof e.ntryl At: <br /> Transporter signature jfor exports only): Date leaving U.S.: <br /> 17.TfansporlerAcknowledgmeni of Receipt of Matedals <br /> Transporter I Pdnlodf€yped Name Signature y,':.yy x ; Month Day Year <br /> CL <br /> CiMon Day <br /> Da Year <br /> � Transporter 7�PrinledffypedNarne Signature r Y <br /> t X16.Discrepancy <br /> 18a.Discrepancy Indication Space quarlily LlType ❑Residue ❑Partial dejection ❑Full Rejection <br /> I <br /> Manifest Reference Number: <br /> 18b.Alternate Facility(or Generator) U,S.EPA ID Number <br /> U- Facility's Phone: <br /> 1 td f8c-SlgnatureolAllemaleFacilily(orGeneralor) Month Day Year <br /> k <br /> l Q <br /> a <br /> S219.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> � <br /> 1 • 2. 3. 4. <br /> 20.Designated Facility Owner or Operator.Codification of receipt of hazardous materials covered by the manifest except as noted in Item 18a <br /> ante �" Signature Mon ❑y Year <br /> Printedf€yped N <br /> r <br /> EPA Form 87004-2-(Rev:3-i15) Previous editions areobso4efe. DESIGNATED FACILITY TO GENERATOR <br /> E <br /> E <br />