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PInrA4r.4 nrint nr tvna (Fnrm rdsctnn Ad for uca nn alila (0.0ehl Ivn a, urHarI <br />crRrorrnwuu•zzlimev.s-uol rrevmuseoltronsare oosolete. MtIGPIATE:D FACILITYTO'GENERATOR <br />UNIFORM HAZARDOUS <br />t. Genera!or Ib Number <br />2, Page 10( <br />3. Emergency Response Phone <br />an lest roc ng um r <br />WASTE MANY EST <br />t:t1Lf%C:i>r);> tt�%E'i(9 <br />i <br />1 W0') /11?11 ';:`tr%:::) <br />004036506 JJK <br />6. Gerivators Name and Mailing Address Generstors Site Address (if di8erenl then mailing address) <br />(''01*!; 0WI iSllli! ill IW;(:Y <br />;" A:31v') AtJ l (J 1't A/A 111; )11 I0 <br />GeneretorsPhone: ?hP) .8'41+ :."Y',c•) <br />6.TransporierICompany Nam U.S.EPAID umber <br />1'a+ I I If; (:(111:; I I! CQ111:lt IIAOt%f;rt4(A!, <br />7. Transporter 2 Company Name U.S. EP ID Number <br />6. Designated Facility Name and Site AddressU.S. EPAID Number ' <br />PACT, f, 4(I`.'a)111iC1: 1ti:1`rlti►( ({y. .. i%i;4H,;',t,.j{: i.:!r,}.r.._•:::<;. <br />:3PA") 1"A"T I"WO CO RI V0, <br />l -W.; Co (JIV l;"I <br />Fac;'; es Phone: ( 804 ) 41"cl • 7 I <br />ga. <br />9b. U.S. DOT Description (bdoluding Proper Shipping Name, Hazard Class, ID Number, <br />10, Containers <br />11, Total <br />12. Unit <br />Hnl <br />end Padd Group d an) <br />09 P( <br />Quantity <br />WrArol. <br />13, Waste Codes <br />No, <br />Typo <br />.-,t•UNl'. <br />; , 1,1f1`; l i F'11101 PIA A VI 11 i1A I IAA AI, , 'i , <br />fh't 3i <br />I chd ;d <br />2 Nllt•I ItCIV, I4l1?f11a)f.)t! i 111fl't IT I-101.1111 ()AA fl R1,101WI <br />IMI <br />CI FAM1ldfi t1't1(i('d) (CAt 11`OIaoil Id-iIIJI.Il1fl) <br />3. <br />4. <br />14. Special Handling Instructions and Additional Information <br />r.I urn:!;, l 06,fi1.4 sK !1,1)'11'(: I'IVI C 101It I tali <br />'A),') NMI <br />112AIiii1�11IiIl tt I 1,1411I4'. I I P)(tfi <br />15. GENERATOWSIOFFEROR'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 />narked and labeled/placarded, and are In all respects In proper condition fx 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 terms o! the attached EPAAoknaxledgment of Consent. <br />I certify that the waste minimizat on statement Identified in 40 CFR 26227(a) p! (am a large quantity generator) of (b) (if l am a small quantity generator) is true. <br />117&aloes/0fferors Printedllyped Name \ ature Month I Day Ye <br />.d <br />16. Intemationel Shipments <br />Import to U.S. ❑ Export from U.S. Port o1 entrylexil: �l <br />11/ <br />Transporter signature ((or exports o*): Date leaving U,S.: <br />17. hensporterAdmoMedgment of Rece`pl of tAatedals <br />Trans/P,Mt Pdn Typed Name "" S' re ` l month Day. . Year . <br />Transporter 2PrintedRyped Name ..._ .... _ ..... Sg/tLre.__ -._..... _.... _ .__..".... . ".._._ .-.._..__M th_ _. Day _._ Year <br />18. Discrepancy <br />18s. Discrepancy Indication Spate E Quy 0 Type ❑ Residue ❑ Partial Re)ect on ❑ Full Rejection <br />Manifest Reference Number: <br />18b. Altemale Facility (or Generator) U.S. EPA ID Number <br />V <br />UZ <br />FacWs Phone: <br />QS <br />For <br />18c. Signature of Nlemale Facility (or Generator) <br />Month Day Year <br />H19. <br />Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste treatment, disposal, and recycling systems) <br />2. <br />3. <br />4. <br />20. Designated Faclity Ovaier or Operator. Ceffo5on of recelpt of hazardous materials covered by the manifest except as noted in Item 18a <br />Prin\Odffyped Name Signature r ` Month Day Year <br />crRrorrnwuu•zzlimev.s-uol rrevmuseoltronsare oosolete. MtIGPIATE:D FACILITYTO'GENERATOR <br />