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Please print or type. Form Approved. OMB No. 2050-0039 <br /> UNIFORM HAZARDOUS 1 . Generator ID Number 2, Page 1 of 3. Emergency Response Phone 4 Manifest ackingNumber <br /> WASTE MANIFEST 1"" - ' ' ,1a °' <br /> 5. Generator's Name and Mailing Address Generators Site Address (if different than mailing address) <br /> t _ ' " .tom i. .. " ! SRrw•.11i4fHS — `3111 r !-i ..nGt <br /> 3 "0 ` T : S 2 0 <br /> Generator's Phone: 4 1 1" i `< - s <br /> 6. Transporter 1 Company Name U.S. EPA ID Number <br /> i .,,A .' 9J , '. . .z _3 for <br /> 7. Transporter 2 Company Name U.S. EPA ID Number <br /> I3s,'„1..0fiysp : `'v_. <br /> 8. Designated Facility Name and Site Address U.S. EPA ID Number <br /> ` . IN,. V�V 11.z, M ,.d i9 9. f <br /> INA <br /> Pill <br /> Facility's f v1 7 `7f 1 . 1 <br /> ga 9b. 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.NoI. <br /> 1R ` < 3. .� t. <br /> r a D T ( 1 t � y 1 1f 1t3 T7 I,'f� 3 c4 <br />(iiNi Iff <br /> r. x19 <br />! � 2 . <br /> u1 <br /> t9 <br /> 3. <br /> 4. <br /> 14. Special Handling Instructions and Additional Information <br /> . 1 - <br /> � n ___ <br /> .. s r a a`:t .. r.:x & a 4i^: a I t ., r f- .,, . � r . , ' ' 'c + z .. t j . n 0I % � � f`�YIt <br /> "' <br /> Ni �. . , .. . . : 18 .. . .. . 3 _ ttM r ,aw vau ., +. _, vis dx .. . _ v <br /> Sill <br /> ii II "ii sy l (3, <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 classed, 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 EPAAcknowledgment of Consent. <br /> 1 certify that the waste minimization statement identified in 40 CFR 262.27(a) (if I am a large quantity generator) or (b) (if I am a small quantity generator) is true. <br /> Month Day Year <br /> GeneratorslOfferors Printed/Typed Name Signature ,r - <br /> NA <br /> LIN) Ni <br /> ❑ <br /> import <br /> } 1 t <br /> 1C. IM n bona Shi ment Export fro U .S. Port of entrylexit: — <br /> p po to U,S. ' r Al' <br /> YJ <br /> ? <br /> Transporter signature (for exports only): ,li r' Date leaving U.S.: r <br /> W 17, Transporter Acknovrledgment of Receipt of Materials <br /> MonthYear <br /> tNNNN Transporter 1 Printedl7ypedName Y 1 l Signature {ter y h rfDay r <br /> Oilt ` S (. ) ( ,t1 I .. <br /> SIM <br /> Transporter 2 Pr tediType Name III <br /> Signature ; Month Day Year <br /> h- <br /> 18. Discrepancy <br /> 18a . Discrepancy Indication SpaceQuantity ❑ Type ❑ Residue Partial Rejection ❑ Full Rejection <br /> Manifest Reference Number: <br /> r 18b. Alternate Facility (or Generator) U.S. EPA ID Number <br /> Nil <br /> J_ <br /> U <br /> W Facility's Phone:. Month Day Year <br /> w I Signature of Alternate Facility (or Generator) <br /> Q <br /> Z <br /> 19. Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste treatment, disposal, and recycling systems) <br />