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Please print or type. (Form designed for use on elite (12-pitch) typewriter,) Form Approved, OMB No. 2050-0039 <br /> UNIFORM HAZARDOUS 1 . Generator ID Number 2. Page 1 of 3. Emergency Response Phone 4. Manifest Tracking Number <br /> WASTE MANIFEST JJ <br /> 5, Generator's Name and Mailing Address Generators Site Address (if different than mailing address) <br /> i <br /> Generator's Phone: <br /> 6. Transporter 1 Company Name U.S. EPA ID Number <br /> 7. Transporter 2 Company Name U.S. EPA ID Number <br /> 8, Designated Facility Name and Site Address U.S. EPA ID Number <br /> Facility's Phone: <br /> ga, gb. U.S. DOT Description (including Proper Shipping Name, Hazard Class, ID Number, 10. Containers 11 . Total 12. Unit 13. Waste Codes <br /> HM and Packing Group (if any)) No. Type Quantity Wt.Nol. <br /> 1 . <br /> O <br /> Q <br /> >v <br /> z 2. <br /> LU <br /> 3. <br /> 4. <br /> 14. Special Handling Instructions and Additional Information <br /> _ r <br /> 15. GENERATORVOFFEROR'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 labeled/placarded, and are in all respects in proper condition for transport according to applicable intemationaland 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 of the attached EPAAcknoviledgment 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) (ifl am a small quantity generator) is true. <br /> Generatorsl0fferoes Printed/Typed Name Signature Month Day Year <br /> —r 16. International Shipments <br /> ❑ Import to U.S. ❑ Export from U.S. Port of entrylexil: <br /> Transporter signature (for exports only): Date leaving U.S.: <br /> Lim 17. TransporterAcknovdedgment of Receipt of Materials <br /> Transporter 1 Printedllyped Name Signature Month Day Year <br /> c,. <br /> Transporter 2 PdntedlTyped Name Signature Month Day Year <br /> F <br /> 18. Discrepancy <br /> 18a. Discrepancy Indication Space El Quantity ❑ Type ❑ I ❑ Full Rejection <br /> Y Residue Partial Reaction <br /> Manifest Reference Number: <br /> fi 18b. Alternate Facility (or Generator) U.S. EPA ID Number <br /> 's Phone: <br /> Icertify et 'ttureofAltemateFacili or Generator <br /> practicablcablm <br /> e . ty ( ) Month Day Year <br /> This Individual t <br /> and materials ar. <br /> by the standard i Waste Report Management Method Codes (i.e., codes for hazardous waste treatment, disposal, and recycling systems) <br /> Service orders with a. 2• 3. 4, <br /> of the eNlnnifest progro <br /> Owner or Operator: Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a <br /> ( u §tomer Sifgnatui Signature Month Day Year <br /> Previous editions are obsolete. E� lj „ t Fr <br /> Print Name , t ,_ € . C' <br />