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Please print or type . ge 1 of Form Approved. OMB No. 2050,0-0039 UNIFORM HAZARDOUS 1 . Generator ID Number 2 Pa3. Emergency Response Phone 4. Manifest Tracking Number K WASTE MANIFEST 0 5 Generator's Name and Mailing Address Generator's Site Address (if different than mailing address) `.1u 1III iz ( ? ,. +t JI Generators Phone: D _1 G 1 r > ` ` r .r v 6 Transporter4l Company Name U.S. EPA ID Number . ., s" MAssA ;1i t F )Id 9 V1' .. .. ri_ II% t. 0sa IIe .ks; c s. .,.� 7 Transporief.2 Company Name U .S. EPA ID Number t. CA , . � : � f _ a. �;;"•; v ; . ,, = ,. .� `21 fl X91 LES , 2. r. 7 8 Designated Facility Name and Site Address _ U .S. EPA ID Number .'. r " ,?jr_ '' J1 , ., _ . : Facility's Phone: 9a gb. U .S. DOT Description (including Proper Shipping Name, Hazard Class, ID Number, 10. Containers 11 , Total 12, Unit 13. Waste Codes HM and Packing Group ('f any)) No. Type Quantity Will �,.3 . .. _ kr.. _C '? e , X49 __ 1 . � , fit 1. 4 . � � , � , f} `� e'_ � � O ip , 1 � 2. W 3 . 4 . on 14 Special Handling Instructions and Additional Informs _, 3 s_0mr ?., ., 02A5 . 6= ' a $� A i � . v � . � 11 11 15. 1 11111 GENERATOR'SIOFFEROR'SrCERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by the proper shipping name, and are classiried, packaged, 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 Exporter, I certify that the contents of this consignment conform to the terms of the attached EPAAcknowledgment of Consent. I certify that the waste minimization statement identified in 40 CFR 262.27(a) (if I am a large quantity generator) or (b) (Ili am a small quantity generator) is true. Signature Month Day Year. GeneratorslOfferors Printedrryped Name . , r r International Shipments f ✓ = 1 Import to U.S. Exportfrom�U.S. Port of entry/exit: Transporter signature (for exports only): $vn " Date leaving U.S.: ME W 17. Transporter Acknowledgment of Receipt of Materials ' Signature Months Day Year Tran o er 1 PfntedfTyped Name ` 115 Mnth Day Year Z T nsponer 2 P ' tedl typed ams * Signature � � �i P t-- 18. Discrepancy 18a. Discrepancy Indication Space Quantity ❑ Type ❑ Residue ❑ Partial Rejection El Full Rejection Manifest Reference Number: 11 11 WIN I 18b. Alternate Facility (or Generator) U.S. EPA ID Number V uZ- Facility's Phone: Month Day Year LM 18c. Signature of Alternate Facility (or Generator) Z: 19. Hazardous Waste Report Management Method Codes (i.e. , codes for hazardous waste treatment, disposal, and recycling systems)