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Form Approved . OMB No, 2050-0039 <br /> Please print or type. <br /> UNIFORM HAZARDOUS 1 . Generator ID Number 2. Page 1 of 3. Emergency Respons Phone 4. Man <br /> Tracking Number <br /> WASTE MANIFEST f . , FLE <br /> r,u t d,. . coy _, 0 G, R a � > ' is fAfA � F = 1 c � . ,r ( Nz m <br /> 5. Generalor's Name and Mailing Address Generators Site Address (if different than mailing address) <br /> V , .. 7C- s w`Lr f ;:14` 1 a } „ ` .rf;: „ <br /> NN <br /> Generator's Phone: <br /> U.S. EPA ID Number <br /> 6, Transporter 1 Company Name <br /> S EPA ID Number <br /> r <br /> ar, U . , <br /> 7. Transporter 2 Company Name <br /> 8. Designated Facility Name and Site Address U.S . EPA ID Number <br /> >,,=` tr <br /> y '. I ' . t '^ fta <br /> Facility's Phone: � y NlN r :M <br /> 9b. U.S. DOT Description (including Proper Shipping Name, Hazard Class, ID Number, 10. Containers 11 . Total 12. Unit 13. Waste Codes <br /> 9a' 1. <br /> HM and Packing Group (if any)) No. Type Quantity Will <br /> 0 ) <br /> 2. <br /> i <br /> I <br /> i 3• <br /> 4 . <br /> r 14 . Special Handling Instructions and Additional Information <br /> IN IN <br /> IN <br /> Lm <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 classified , packaged, <br /> marked and labeledlplacarded, 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 terms of the attached EPA Acknowledgment 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) fill am a small quantity generator) is true. <br /> Generator'slOffero 's Printed/Typed Name Signature Month Day Year <br /> 16. International Shipments Import to U.S. ❑ Export from U .S. Port of entry/exit: _ . <br /> a Date leaving U.S.: <br /> z Transporter signature (for exports only): <br /> W 17. Transporter Acknowledgment of Receipt of Materials <br /> LLJ Transporter 1 PrintedlTyped' Name Signature Month Day Year i <br /> r' <br /> CL <br /> NNI , ,, <br /> t I r = . . I� <br /> Transporter 2 Printlyped Name Signature Month Day Year <br /> 18, Discrepancy <br /> 16a , Discrepancy Indication Space Quantity ❑ Type ❑ Residue ❑ Partial Rejection ❑ Full Rejection <br /> Manifest Reference Number: <br /> U.S. EPA ID Number <br /> 18b. Alternate Facility (or Generator) <br /> .J <br /> V <br /> LL Facility's Phone: Month Day Year <br /> LO 18c. Signature of Alternate Facility (or Generator) <br /> 4 <br /> rdous waste treatment, disposal, and recycling systems) <br /> 19. Hazardous Waste Report Management Method Codes (i.e., codes for haza <br />