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Please prin pe.(Form des' ed for use on elite(12-pitch)tYPewriter.) <br /> FORM HA S 1. orator ID Number 2.Pag 1 of 3 E r e cy a nse Pa e N er <br /> WASTE MANI EST ,t i>' 7,0 a 12� � `fix <br /> 5.Generators Name and Mailing Address Generator's Site Address(if.different than mailing address) <br /> Generator's Phone: <br /> 6. Atr' 11y"Lo r a � t "a f sr;fifefisti .f U.S.EPA ID Number k{y. <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> 8.Designated Facility Name and Site Address xit a�,�.,)t! r s•�t p (, �gf $�r U.S.EPA ID Number <br /> WA-86 SMITH "AVF,4 <br /> ij f il�i CA 941-160 <br /> Facility's Phone: <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 /> 0 V0 <br /> t <br /> C5 Tr <br /> 3. <br /> 4. <br /> 14.Special Handling Instructions and Additional information <br /> t� D . kt E <br /> ��`i` �,e .�bM�-��;�111 � '�-��•.�- :, .. `yam k... <br /> 15. GENERATOR'S/OFFEROR'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 Intemational ago national goVemmentaf 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 Cons <br /> I certify that the waste minimization statement identified in 40 CFR 262.27(a)(if I am a large quantity generator)or(b) a small quantity generator)is true. <br /> Genera rs/Offeror's Printed/Typed Name Signature Month Day Year <br /> i' <br /> .j 16.International Shipments <br /> t ❑Import to U.S. Export froth U.S. Port of entry/bxit <br /> Transporter signature(for exports only): Date leaving U.S <br /> W 17.Transporter Acknowledgment of Receipt of Materials <br /> ransporter 1 Pdnted/Typed Name fPOnature Month Day Year <br /> t <br /> Z Transporter Pdntedrryped ame Signature V Month Day Year <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space - Quantity ;, ❑Type ❑Residue. Partial F-1FullRejection <br /> ❑Partial Re action <br /> Manifest Referenoe.Number: <br /> 18b,Alternate Facility(or Generator) U.S.EPA ID Number <br /> Facility's Phone: <br /> W 18c.Signature of Alternate Facility(or Generator) Month Day Year <br /> Q { <br /> Z <br /> N19.Hazardous Waste Report Management Method Codes(Le.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> G 1. 2. 3. 4. <br /> I ! f S <br /> 20,Designated Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a <br /> Printed/Typed Name - Signature Month Day Year <br /> A Fgrrt87 22(nevi,3-05) Previous editions are obsole DESIGNATED FACILITY TO GENERATOR <br />