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Please Dilrillor tvae. (Fnrm fip.-qinnpd fnr noim nn alRa 119. ith! 4 , ..4— <br />DESIGNATED FACILITY TO GENERATOR <br />:r - - I-Ul III nFV1VvUU. UIVID 111u. /VDu-maF <br />UNIFORM HA ARDOILIS I. Generates 11) Number 2.Page lof 3. Emergency Respo(ise Phone 4. Manifest Tracking Number <br />"WAS NIFEST <br />J J K <br />5. 06librator's Name and Mailing Address Generators Site Address (if different than Mailing address) <br />JK,J G <br />28'X) A I fj i A'7' �' 6R #Y70 <br />G .. rit h&. <br />6. Transporter I Company Name U.S. EPA ID Number <br />7.Transporter 2 Company Name U - S. EPA ID Number <br />B. Designated Facility Name and Site Address U.S. EPA 10 Number <br />D <br />4onw. <br />Facilty s i'l %j <br />ga. <br />9b. U.S. DOT Description (including Proper Shipping Name, Hazard Class, ID Number, <br />10. Conta oars <br />111. Total <br />1Z Unit <br />HM <br />and Packing Group (if any)) <br />Quantity <br />WI.IVOI,1. <br />13. Waste Codes <br />No. <br />D h A i <br />L <br />1i 4 <br />Z <br />LU <br />0 <br />2. <br />i A e" 8 R 1 0 U W A I 1.. 40 -1 j I A 0 R ij 1. <br />UI,. A 110 t <br />ON L Y <br />.. ........ — <br />N'0N WA', IV'(- y 1'. N <br />'A L A 1 N A RE G U I.- A'T I" <br />4. <br />Rt HAZARL)1lir Sz- WAS -IE 1-10010 `w A,] IE R B 0 R N E <br />14. Special Handling Instructions and Additional Information <br />AP$ 639b W-14) Af-'# <br />& f'lf - ;01FC.`T 1VE CZ -0TH -0463 <br />t� 9 b 4 N 0 tYIE <br />15. GENERATOKSJOFFER611'�CE�M �' i rt c <br />reby 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 labeled/placarded, and are in all respects in proper condition for transport according to applicable international and national governmental regulations. If export shipment and I am the Primary <br />Exporter, I certify that the contents of this consignment conform to the term of the attached EPA Acknowledgment of Consent. <br />I certify that the waste minimization statement identified In 40 GFR 282.27(a) (if I am a large quantity generator) or (b) (ill am a small qujngty generator) is true. <br />esfOfferoes Pdnteffyped Name S�n M <br />.tu. 01th Day Year <br />A OS I <br />J <br />, <br />15. In etnatlohal SN04*ts <br />Import to U.S. El Export from Port <br />ofenvyiexit:) <br />Transporter signature (for exports only): Date leaving U:S.J' <br />W <br />17. Transporter Acknowledgment of Receipt of Materials <br />Ej <br />Trans",.I.Printed/Typed Name Signature Month Day YOU <br />0 <br />CL <br />Z <br />Transporter 2 PrInted/Typed Name S"(dn§ Mor((h Day Year <br />18. Discrepancy <br />,18a. Discrepancy. Indication Space quantity El Type ❑Residue Partial Rejection ❑Full Rejection <br />Manifest Reference Number; <br />l8b, Alternate Facility (or Generator) <br />U.S. EPA ID Number <br />I.L. <br />Facililys Phone: <br />1 <br />0 <br />LLI <br />I fic. Signature of Alternate Facility (or Generator) Month Day Year <br />I- <br />19. Hazardous Waste Report Management Method Codes (i.e.. codes for hazardous waste treatment, disposal, and recycling systems) <br />2, <br />3 <br />4, <br />t.r <br />20. Designated Facility Owner or operator. Certification of receipt ofiazai l&s milerials covered by the manifest except as noted In Item+ 18a <br />mer <br />Printednyped Name Signature Month Day Year <br />DESIGNATED FACILITY TO GENERATOR <br />