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t Please pfintortype. <br /> Form Approved,OMB No.2050-0039 <br /> UNIFORM HAZARDOUS 1.Generator ID Number 12.Page 1 of 3.Emergency Response Phone 4.Manifest Tracking Number <br /> WASTE MANIFEST _ I 0 F L E <br /> -r-r ,_..-,r�, <br /> 5 Generator's Name and Mailing drese Generators S'a ress(if different than mailing address) <br /> iw ir i <br /> 1)�S J31 Erni 560 Nt R I H MAIN STREET I 560 t~tOR f f t Wi I IN 3-f REL T <br /> Generator's Phone: - <br /> 6 Transporter 1 Company Name _ -1J.5 E 'ID Number <br /> 7.Trerrsppri Company arae U AID Number <br /> T+L~i s;�q; ✓��'� RADS .r C_L I tl` ep o5ly 3d's f <br /> B.Ues gnaled Facility Name and Site Address _ t U.S.EPA ID Numbe( <br /> CeCrt;.ry EMN, L1_G <br /> C ira' N t:tN i a n t.l= U t ., E;:o_1 <br /> ret Tiley, Nit; 59408 <br /> Facilil's Phone: -y5�?e:, ts; <br /> ,�a---c <br /> 9a. 9b U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers11.Total 12.Unit <br /> HM and Packing Group(if any)) 13.Waste Codes <br /> No. Type Quantity Wt.Nol. <br /> c ;Y 'UNI-791, Taste Hypochlorite SODUtions 8, PG 1 OF 00023 P D00 <br /> 1 J 1. ERS;#15 <br /> w <br /> X 2UN1950, Waste Aerosols, flainiti le 1, ERG#126 1 CF 00013 F 331 Dio01 <br /> 3. <br /> 4 <br /> 14.Special Handling Instructions anc[Addifiwl Information i <br /> - 110517 81.each, Liquid) 2. 110541(Asrosols) <br /> 15, GEN ERATOR'SlOFF'EROR'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 certify that the waste minimization statement identified in 40 CFR 262.27(a)(if(am a large quantity generator), (b)(if I am a small quantlty'gertergbr)Is true. <br /> G7f Pdptedltyped N e y Si t o Month Day Year <br /> Z 1fi emal onal Shipments ❑Import to U.S. �� <br /> El Export U.S. Port of <br /> sporter signature(for exports only): n Date le rg <br /> x 17.Transporter Acknowledgment of Receipt of Materials <br /> Transporter 1 Printed/Typed Name Sig ature // Month Day Year <br /> Ranthany iMac <br /> Transporter 2 Pnnted/Typed Name Si at Month Day ear <br /> 18,Discrepancy <br /> 18a.Discrepancy Indication Space ❑ Quantity ❑Type El Residue ❑Partial Rejection F-1 Full Rejection <br /> Manifest Reference Number: <br /> 18b.Alternate Facility(o Generator) <br /> � U.S.EPA ID Number <br /> v <br /> LL Facility's Phone: I <br /> W 18c.Signature of Altemate Facility(or Generator) Month Day Year <br /> Q <br /> Z <br /> W19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> 0 1 ( 4( 3 14 <br /> 20.Designated Facility Owner or Operator:Certification of receipt 17.rd ..materials covered by the manifest except as noted injW 18a <br /> Fnn Mi <br /> a � igr — � Month Day Year ' <br /> EPA Form BTOa { ev. 2.1 Previou hlon5 are obsolete. ESIGNA ED FACILITY TO EPA's e-MANIFEST SY T M <br /> 5700--22_12,d CAL2007P032 S41053287 0413 79819 M PD10142219 3D042219 <br />