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M cn M cn <br /> m <br /> = 3 <br /> (D O o go <br /> 0 <br /> to -T1 <br /> Q C v <br /> O <br /> II III II VII I ILII III II II I III II <br /> IT Form Approved OtASNo 2U'G-0G39 3 W <br /> C/) please printer tyHAL4RDO11S pe. Y.Pagelot J-Emergency Response Phone 4.Manifest Tracking Number 7 <br /> UNIFORM J <br /> 1.Generalor lO Number 012497656 FLE <br /> � <br /> WASTE MANIFEST Generators Site adersss'fit d�nerent Ihan mailing addrassl <br /> 5.Generalols Name and Ahaling Address <br /> 1y <br /> P <br /> Generator's hone. a`.EFa.tp Number <br /> F.Trwsp"r 1 Company Name N <br /> u.S.EPk IG Ifumber r <br /> Transporter 2 Company Name 7 <br /> U.5-EPA ID Number <br /> 8.Designated FacBlry Name and&ile Address <br /> O <br /> 0 <br /> O <br /> Faplity's Phone: <br /> ao-U S.DOT Descdpl on(i Audtng Proper&hipping Name.Hazard Cla s,10 Number, 0.Containers u Total 2 Unit Wade Godes <br /> 9a. No Type <br /> Quany Wt.Nol. <br /> HM and Packing Group(A anY)1 blD <br /> O <br /> Q <br /> Z 2. <br /> C7 <br /> in w <br /> I.,&penal Handling lrelmcWS and Additional 3nformai <br /> 15. GENERATOR'StOFFEROR'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 fit placardi and are in all respects in proper condition for transport according to applicable intemalional and natlonal governmental regulations.II eyped shipment and I am the Primary <br /> FF3•porler,s certify that the <br /> contents of this rr riment conform to the teens of the attached EPAAcknovdedgment of Consent. <br /> I rR*that the waste minim ion statement identified N 40 CFR 262.27)a)(e I am a large quantity generator)or Obi(if I am a small quantity generator)is true. <br /> Generatofs,011 Ws PrintedTyped Name Signature Monte Day year <br /> , 1b.Intematior4Shipments <br /> f,. ❑Import!to U.5- ❑Erpod from U.S. Pon of entrylewiC <br /> ? YrarspMer signature(frr eryorfs tiny).- Dale leaving U.S.: <br /> IX 17.Tri nsperterAyurfavedgirrenf of Receipt of Mai l5 <br /> Transporter 1 PNiled,'fypm Name <br /> O Signature Month Day <br /> IL <br /> T,—porter 2 Pray E yped Name <br /> co <br /> Signature Month Day <br /> IBa Discrepancy edica6on S - ... <br /> ❑oue'td, 0T1fPe ❑Residue ❑padial Rejection <br /> ,�A�+raie Fats Ion Ga�radorf Manrtesl Reference Number <br /> U.S.EPAID Number <br /> U <br /> a <br /> 4 Faoitys Phone. <br /> 1 Sg+aoee d Alternate Facii for Generaiorl Mc,dn Day Yom <br /> z <br /> `S.Hazardous v:asl�-Psi Vxagemerl yAeltsod Codes f,.e..rides for hazardous waste Itealbri 05poBai.and mn <br /> recycling,yswj (� <br /> 2 J <br /> 1r�C Faofry ow_ Op sap EJhfraun d recogl d para n,F matena s n:ere,1 by the marutest excep as n Wd Item 1 Ba <br /> DQ <br /> (carne nature <br /> Month Day i'ev = Q <br /> (!� EPR.Fx n 97pfr22 ERer.12-171 Preva n are Ubsofete <br /> N N <br /> GENERATOR'S INITIAL COPY o <br /> O cin <br /> w <br /> w <br /> w <br />