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Please print or type , _ Form Approved . 0MB No. 2050-0039 UNIFORM HAZARDOUS 1 . Generator ID Number ? Paye 1 of 3 Emergency Response- Pno e 4 Manifest Tracking Number WASTE MANIFEST „ ; 1 < , — ' . . 8 _ „ E z u , � � 5, Generator's Name and Mailing Address Generator's S le Address (if different than roailing address) *`z mi Generators Phone: 6. Transporter 1 Company Name U . S . EPA ID Number Sq 7, Transporter 2 Company Name U,S. EPA ID Number 8. Designated Facility Name and Site Address _ U .S , EPA ID Number i , zr a q e2 mar T Facility"s Phone: D `_iy . ` * a 91 9b. U. S. DOT Description (including Proper Shipping Name , Hazard Class, {D Number. 10 . Containers 11 . Total 12 . Unit 13. Waste Codes HM and Packing Group (if any)) No. Type Quantity Wt.Nol. SMMOIJ � �5141na Ina 14 ) kt Uj 2LU 3 I � f 14 . Special Handling Instructions and Additional Information M X-S6, WhRmpt r w f t r 51 104;lS "if Sir r 15. GENERATOR' §lOFFEROR'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, marked and Ipbelediplacarded , 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 Exporter, I certify that the contents of this consignment conform to the terms of the attached EPA Acknow edgment of Consent. i I certify that the waste minimization statement identified in 40 CFR 262. 27 (a) (If I am a large quantity generator) or (b) r f I am a small quantity generator) is true, Generator's/Offeror's Printed/Typed Name Signature �r r` Month Day Year c 16. International Shipments ❑ �''Import to U . S . Export from U .S . Port of entry!exit Transporter signature (for exports only): Date leaving U .S. : W 17. Transporter Acknowledgment of Receipt of Materials Month Da Year _ Transporter lentedRype Nam Sign lure14A y Y SP Transporter 2Printed/ Iype'dNarme F Signature Month Day Year 18. Discrepancy 18a . Discrepancy Indication Space Quantity El Type Residue El Partial Rejection Full Rejection IJianifest Reference Number: h 18b. Alternate Facility (or Generator) U.S. EPA ID Number Facility's Phone: UJ 18r,. Signature of .Atemate Facility (or Generator) Month Day Year 19, Hazardous Waste Report Management Method Codes (i.e ., codes for hazardous waste treatment, disposal, and recycling systems)