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Please print or type.(Fam designed for use on elite(12-pith)typewriter.) Form Approved-OMB No',205 0039 <br /> UNIFORM HAZARDOUS 1.Generator 10 Number . 2.Page 1 of 3.Emergency Response Phone 14.Mx&d gmaw <br /> WASTE MANIFEST v rri t ' ^3 f 47, + '+ t7: I 1 t. t ) 010 f � <br /> 5.Genwalor's Name and MaIN Address Genera[ofs SdeAddress(nf 0i3rent thw makV address) !/ <br /> Generator s Pham' ?. <br /> 6.Transporter 1 Company Name., U.S.EPA ID Number <br /> T.Transporter 2 Company Mane U.S.EPA ID Number Cf <br /> 8.Designated Fadlity Name and Site Address U.S.FPA fl)Number <br /> Faaliys Plane: . •r , } . .. <br /> 9, 9b.U.S.DOT Desaiptim(aMudag Proper ShOpng Name,Hazard Class,ID Number. %Contai ars 11.Total 1z" 13.Waste Codes <br /> HM and Pack ng Group(d anry)) No. Type Quantity NRNbi. <br /> z 2- <br /> LU <br /> 3. li <br /> i <br /> 4. <br /> 14.Special Han*mg Instructions and Add'bi tint Infomrabon <br /> '.s _ f <br /> 15. OENERATOR'SfOFFEROR'S CERTIFICATION:I hereby declare Rel the contents of this consoun nt we hilly and amrataty deschbed above by the proper shipping name.and are dass&K!,padwged, <br /> marked and faheledlptauarded,and are In a lreM eciz M proper condition br transport aomndrg to a ppk&e nmmetimal and national pam msanial regulations.BeNpat ftment and I am Rue Primary <br /> Eporter,I certrfy that the conlents of Nissignment conform lo the terms of theatladled EPAA*0*166grnent d Consent <br /> 1 oef01y ow ft waste rtdrrgr12abon identified in 40 CFR 26227(a)(if I am a lags quar*generator)or(b)(W I am a small quantity generator)is true. <br /> GeneratnrsWerues Pm*WTyped Name Signahae Month Day Year <br /> F 16.Intenatlo sal Shipments Elimport U.S. ❑E,.from U.S. Port of enstrylexft: _- - <br /> z T-Worter stprahrre(for exports only): Date leavng U.S.: <br /> W 17.Tra wWWAdm0edgmerdof ReceO ofMalarials - <br /> 9 Transp W 1 PdrtedlTyped Name SV— Montt Dray Year <br /> y ! �• �.. ,r. '� ` .,.f-'.�,� n ryr_ ver ^f <br /> Transporter 2Printed/Typed Name SigrwWre Month Day Year <br /> Ix <br /> 16.D&repancy <br /> 18a.Discrepancy hsdreation Space ❑ Ouajrtity ❑Type ❑Residue ❑Partial Rejection ❑Fup Rejection <br /> Manifest Reference Number. <br /> 18b.Akmale FacW(or Generator) U.S.FPA fD Number <br /> J <br /> U <br /> LL Fadffo Phone: <br /> w 18c.Signature of Alternate Faddy(or Generator) Moth Day Year <br /> a <br /> z <br /> 019.Hazardous Waste Report Management Method (i.e.,codes for hazadons www treatment,dis osal,and recycling systems) <br /> G 1. :2- <br /> ` 2 3. 4. <br /> to <br /> 20.Designated Fealfty Owner or Operator.Cerb5ca ion at receipt of hazardous materiels covered by fie nrersTest except m wedn item 18a <br /> rinfedfiyped Name Signahrte Math Day Year <br /> 54 <br /> EPA Forth 87022(Rev.305) Previous editions 4ire obsolete. TRANSPORTER'S COPY <br />