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Please print or type.{Form designed for use on elite(1R pitchy typewriter.) ' fi { Form Approved.OMB No.2050-0039 <br /> UNIFORM HAZARDOUS. 1.Gerteralar ID Number', . 2 Page 1 of 3.tmorwcy 4.Marlifest Traclung Number <br /> WASTE MANIFEST 016674352 JJ K <br /> 5 GeneratoCsNattie and Mai6{i9Addre s (if different than mailing arhfress) <br /> po <br /> &TrMtspo h3rit Coop-t;f U.S.EPA ID Number <br /> T.Transporter Company Name U.S.EPA 11)Number <br /> &.Desigpated Eat�7Ry Mame atidSttaAddrt3bs; r, _t. ;r t) <br /> Own u <br /> 25M W%Md Cf�CJ9Rf]A7', P$ <br /> FacirAys Pl>one: t l <br /> 9a 9b.U.S.DOT Oescipbon 0ndudi g Proper Shppbg Nave,Hazard Class.m Number, 10.Containers 11.Total 12.Unit 13.Waste Codes <br /> HM and Pack"'9 Group(d any)) No. Type Quantity WUVol. <br /> o 1" Rr-RA f rllrlk"W%Wv 3{Fly ow,D ) t CM T 352_ <br /> J6 i <br /> M 2 ) <br /> LU <br /> c� <br /> 3. <br /> i <br /> i <br /> 4. j <br /> 14.Special Harding Instructions and Additional; <br /> FK-&#V1 WDM' P.F-E Pm% td9521 - <br /> 1-7 49-5-267 <br /> 15. GENERATOR'SIOFFEROfUS CERTIFICATION: I hdreby declare that the contents of this consignment are fully and accurately described above by the proper shipping name,and are dassiW,packaged, <br /> marked and Mbefedlplacarded,and are in all respects in proper condition for transport according to applicable international and national governmental regulations.ff export shipment and I am the Primary <br /> Exporter,I certify that the contents of this consignment conform to the terms of the attached EPA AckrxA figment of Consent <br /> I ce"that the waste minimization staternerrl identiW in 40 CFR 262.27(a)(if I am a large quantity generator)or(b)(if i am a small quantity generator)is true. <br /> GeneratoesnfTefoes PrWedlTyped Name Signaiufe Month Day Year <br /> jEE?y'Fi«_t�tld3t'tSlR ]dot /V <br /> 1 �f r- v <br /> =J 16.International Shipments rr� <br /> Z ❑Import to U.S_ LJ Export from U.S. entrylexiL— _- -- _--- . <br /> Transporter signature(for exports only): ate leaving U.S.: <br /> 17,Transporter Acknowledgment of Receipt of Materials <br /> Transporter 1 Pr mWTyped Name / Signatrae ! Month Day Year <br /> za Transporter 2 P*Ied/TypW Nam S e Month Day Year <br /> r- <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space El Ouantity ❑Type L !Residue ❑Partial Rejection ❑Full Rejection <br /> Manifest Reference Number. <br /> 18b.Alternate FarAlyr or Generator) J U.S.EPA ID Number <br /> -J - <br /> U <br /> Facility's Phone: <br /> W 18c.Signature of Alternate Facility(or Generator) Month Day Year <br /> Q <br /> Z <br /> N <br /> 19.Hazardous Waste Report Management Method Codes((e.,codes for hazardous waste treatment,disposal,and recyding systems) - <br /> 20.Designated Faal ty Owner or Operator.Certification of receipt of hazardous matemts covered by the mantFr-,3t except as noted m Item 18a <br /> Rnted(f N2tile Signaillte Month Day Yeaifr <br /> EPA Form azWzz(Rev.3-05) Previous euftions are obsolete. �f DESIGNA t D;FACILITY TO GENERATOR <br />