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<br />Ise prirl or ty o. (t orm des
<br />UNIFORM HAZARDOUS
<br />WASTE MANIFEST
<br />for use on 01110 (1
<br />Forth Ap;.roved. 0!.18 No. 2050-0039
<br />4.IA�d 'Mug V 90 FLE
<br />5. Generalots Normo and klmbng Ad rasa GoneratrAS She M�ess In a cc,Ecr ua-, rra- rg a�iresl
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<br />5ulNe+r Got►!d M:>tDcol FuutLI "iu Glucklun Mau cA 1'i��a ;v'Irr Gw1d IMcticel Fadulic 6locklpn IAsd�wl tea
<br />fso5 W Hags aitiir 1 n ?Wj W Han�r►►� 111
<br />Istudim, (A V, 'kill Auuklun, CA VAD"))
<br />Genoratoes Phonw 5!!!&:02 4093
<br />6. ransporter ompany emo US EPA ID N�,"rPr
<br />1 {�n(IhlAiL,e 6uMa u, (.41 rIrr)37t ► J /,
<br />`noN CS 7ectx�u`rl .�itt{UtIUfiG U.0
<br />1125 Ifs► :it, CATut W14079
<br />ftit:InTwnd (A 04011111
<br />Facility's Phone: 1101IQ433 x'.: 1
<br />ga, 9b, U.S. OOT Descdpl on (including Proper Shipping Name, Hazard Class, ID Number, 10. Conla�ers 11, Total 12. UM 13 Waste Gies
<br />HId and Packing Group (if any)) No. Type Ouantity WV1oI
<br />I
<br />1' UWIII51,1�Jrc,ta Stle,�ticlnu, liyt►id, tul:it;, n,u.fa. (1:t�r;tJrn��thttiie}, l f•S1 � 004ti
<br />X 11.1 , N L/ OF P
<br />2, L P124111, �r W: Ae Toxic k
<br />sckts, txual , a,u.s. (1�1maull, 6.1 ,11 [ P Al 0011 W24
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<br />3,
<br />UN19M. Waste Fiimmable Ikr',tulds, me.s. (12MA Alc00
<br />", 292 01
<br />X hvpft SRA 3, U 1 DF t; P
<br />UN1a;51, W�la A1sflici►ta, t'lsyui>s, toxic, n.u.r. �CNIt�lanlbucil,
<br />x rt'"A h'1d,110i,), 6. i , N
<br />t�f6 U150 --I (t�06
<br />14. Special Handling Instructions and Additional lntormatron D�ctcTront. D2348074
<br />iP t3774?g EkC;it<i51, �
<br />2) 877430ERtiR15�1 r i �,( �'r: 4) 961531 ERG1151 311 1 e lt=
<br />15. GENERATOR'SIOFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by the proper shipping name, and are dassili packageds
<br />marked and labeledrplacarded, and are in as respects in proper condition for transport according to applicable International and national govemmenlal regulaWns. If export shipment and I am the Pnmary
<br />Exporter, I certify that the contents of this wnsi9nment conform to the terms of the attached EPAAckno+dedgmenl of Consent,
<br />I certify that the waste minimization statement identified in 40 CFR 262.27(a) If I am a large quantity generator) or (b) (if I am a small quantity generator) is We.
<br />Generalot 0 aro sPnnledf Name g a Y
<br />re on ay
<br />S G
<br />16. Intemabonal Shipments
<br />11Import to U.S. Export from U.S Port, of entiylexil:
<br />17. Transporter AckrwMedgmenl of Receipt of Materi
<br />10. Disaepancp
<br />100. Disaepancy Indration Space
<br />tOb.NlemaleFatil�ty(orGeneroto
<br />J_
<br />+4 Fadtis Phone:
<br />y tic. Signature OlNlemaleFaeidy
<br />n19. Hazardous Waste Report Maw
<br />1 11M1
<br />I20, Desgnated Facility O+meror C
<br />Pdn;edTyped Name
<br />als
<br />t It V:%
<br />J
<br />❑ Quantity
<br />Method Codes (ce., rbdes for hazardous waste Ueatmenl, disposal, and
<br />of receipt (ha a s malertals covered by the manifest exce
<br />� �r'i1 fi��/Ipn.aJ
<br />IPA Form 870042 (Rev. 3-05) Previous edi0ons are obsolete.
<br />❑ Rosidue ❑Partial ReJecion
<br />pt as noted In Item 100
<br />Number
<br />'I
<br />❑ Full Rejection
<br />J
<br />
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