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Vi0L4*rh9,q 11 ZOZ <br /> 039 <br /> Form Approved.OMB No.2050-0 <br /> -pitch)typewrfteuji-� <br /> Please print or type.(Form designed for use on elite(V bar <br /> 3. <br /> Emergency Response Phone 4. <br /> 11,Generator iuNumber <br /> 4, UNIFORM HAZARDOUSFLE- <br /> -6te Al <br /> WASTE MANIFEST Ft than mailing address) <br /> ='Generators <br /> —5.Zp--er`st-0?-S-9a-m--e`-e—n I uling Address <br /> r <br /> ."re' hone'. U.S.EPA ID Number <br /> . <br /> Name <br /> IL U.S.EPA ID Number <br /> 7.tinsporter 2 Company Name <br /> U.S.EPA 10 Number <br /> II. <br /> Designated Facility Name and Site Address f <br /> ENVIRONMENTAL HEAD,'H <br /> 1:jclIi i Pho a: ME 10.Containers ii.Total 12.Unit 13.Waste Codes <br /> 38. 9b.U.S-DOT Description(including Proper Shipping Name,Hazard C PA No. Type Quantity Wt.Nol. <br /> HM and Packing Group(9 any)) <br /> 0 1-f <br /> 2. <br /> LU <br /> 3 <br /> 4. <br /> 14.Special Handling Instructions and Additional Information <br /> iii. 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 labeled/placarded,and are in all respects in proper condition for transport according to applicable International and national-jovemmental 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 /> anli <br /> _j,er,,,,t,011 or(b (if I <br /> I certify that the waste minimization statement identified in 40 CFR 26227(a)(if I am a large qu rTpAqr)or(bL(if IBM a small quitntity generator)is true. Day YeF r <br /> Tre <br /> ne,toe er a me ame I" <br /> 16.Intemational ShipmentsImport to U.S. ❑Export from U.S. Port of entryli.lit: <br /> Date leaving S.: <br /> Trans iter si nature for ex rte on <br /> 1Z 17.Transporter Acknowledgment of Receipt of Materials i-- Day Year <br /> W Signdtu�e <br /> to'-1: Transporter I PrintedfTyped Name <br /> C. Ye wr <br /> i <br /> v. Transporter 2 Printed yped Name gnatu <br /> 18 Discrepancy <br /> 18a.Discrepancy Indication SpaceEl ou-tity E]Type ❑Residue ❑Partial Rejection ❑Full Rejection <br /> Manifest Reference Number: <br /> U.S.EPA ID Number <br /> [j-8b­.Ajtemate Facility(or Generator) <br /> -3 <br /> IR I Facility's Phone: I Month Day year <br /> IGenerator) <br /> �.SnatutecfAltern <br /> CD 19.Hazardous Waste Report Management Method (Le.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> V) 3. <br /> LU 2. <br /> except as F20.Designated Facility Owner or OPOCell0r:Certification of receipt of hazardous materials covered by the manifest ex pt Monts pay 1 ear <br /> PtinjeorTyped Name Fj Signature <br /> ACILITY TO GENERATOR STATE(IF REQUIRED) <br /> 1k, Previous editions are obsolete. JE"Ki 1ATED F <br /> L <br />