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r <br /> Please print or type.(Form designed for use elite(12-0ch)typewriter.) Form Approved.OMB No.2050-0039 <br /> UNIFORM HAZARDOUS 1.Generator ID Number 2 Page 1 of 3.Emergency Response Phone 4.Ma ileg Traddng Number <br /> wasrE MANIFEST l i; 0 1 "r M W <br /> 5.Cements Name and Madsg Address Generators Sr6eA !(d dNererd than marling address) <br /> Gerw&Ws Prone. 1 i <br /> 6.Transporter 1 Company Name P.S.EPAM Number . <br /> y1 <br /> 7.Transporter 2 Comparry Name U.S.1!PA1D Number <br /> 8.Deslgnaled Faci ty Name and Sae Address U.S.EPA ID Number <br /> FadWs Phone: <br /> 9, 9b.U.S.DOT Description(krJuding PrOw SPPmg Name,Hazard Class;tDNumber, 16.Containers 11.Total 12.Unit 13.Waste Codes <br /> HM .and Padcng Group(deny)) No. Type y WWd. <br /> Ix <br /> 1. <br /> Z 2 <br /> W <br /> 0 <br /> 3. <br /> 4. <br /> 14.Special HarKNq Instructiians and Addbonal lydomration <br /> 15. GENERATOR'SlOFFEROR'S CERTI :I hereby dedaie that the contents of this rorsgnneent are fully and acasaWy dried above by the proper shipping name,and are dassfied,packaged, <br /> marked and labek dlplakatded,and are m i A.respects in proper cod Mon for transport according to appicabie in6rnational and rational govenutttel regula5om ff resort shipment and I am the Primary <br /> EW dw,i MW that uta contents of the cbnsignnnarnt oondorm In the terns of the attached EPA.,ck owledlgrnent of Consent. <br /> I cw*that the waste minirrf¢aUon stalm wd ider>6fied in 40 CFR 262.V(a)(d I am a large quarddy generator)or(b)(d)am a smai quanMy generator)is true. <br /> Generabrs70brors Prattedr yped Name Signature Month Day Year <br /> �j 16.International Shipments Q to U.S F_ <br /> ❑ xpat from U.S. Port of entryfexit <br /> t= Transporter W aare(for exports only): - Date INFvkg U.S.' <br /> W 17.Trarc:por"AcknaMedgrnentofReceipt ofMWmals <br /> Ir Transporter 1 Name i s9nature Month Daay� Year <br /> EL <br /> to <br /> Z Transporter 2 Printedrryped Name Signature y Year <br /> 18.Discrepancy <br /> 18s.Discrepancy Indication Space ❑ O�ard ty ❑Type ❑Residue ❑Partial Relied. ❑Fuf Reled. <br /> Manifest Reference Number: <br /> 18b.Altamale FadRy(or Generator) U.S.EPA ID Number <br /> J <br /> U I <br /> LL FadWWs Phone: <br /> W18c.Slgnat re Of Alternate Fadity(or Generalor Month 04 Year <br /> Q <br /> Z <br /> 19.Hazardous,Waste Report Management Meg*Codes(ie.,codes for hazardous waste treabmeM disposal.and recycling systems) <br /> LL, 1. 2 3. 4. <br /> 20.Desgnated Facr6�y Owner or Operator of receipt yf hazardous materials ooverpd by the mardest exmpt as Wed in kern 18a <br /> Ptinledlfyped Name' Srgnatrae Month .Day Year <br /> EP " i s are obsolete. TRANSPORTER'S COPY <br /> X,f�.,--.;.:�'r`�rYin�s`!;.''�` "10:8... +�.'.a�?.i�'Xn 8 -:.'�;Sn+35:d'.t•S�aiB.�C��i '�,f�XYF�r���,'e .:?��f %�'s;�":d..rS+rz.3� .�i._?ark..«" .•?.i','� :.�.is'r9�d:�- <br /> t <br />