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f=ormApPf,V,W,OMB No.2050-0039 <br /> (Man at rac Ina Number �f ■ <br /> ter.) n Responae Phone 1► 11 Ing. 1 f 1 7 K <br /> e Form designed for use on®lits(1N h 2•Page 101 1-1 <br /> e J J <br /> Please rint or I I.Generator ID Number <br /> UNIFORM HAZARDOUS oneralnte roe ress(if event ,an mailing address) <br /> WASTE MANIFEST <br /> $.GeneratDea Name and Melling Ad6l1 WFC 1 <br /> 1 i C4 Ell. .C1ftAt)CJ q F'1 <br /> (':A U.3.EPA 10 Number <br /> u? <br /> Generawa PhonC;A14060 t 11(1'17 <br /> g. ransporter 1 Company erne !ti�If s4; Iyluv�a I U.S.EPA ID Number <br /> F'Ftl�h <br /> 7.TtansPorter 2 Company Name I -PL.+ • a } t ..�' <br /> 1 y U.S.EPA ID Number <br /> } 1, tY It t�y,4, cnr,'.y'W3 <br /> 8.Designated rm3lte Addross <br /> 216, .e4luFtY tM <br /> 2001 , INL"f,NIr�OR 1A, to.T <br /> FERN CY,14V .�6f�C7ii <br /> 11,Total 12.Unit 13.Waste Codes <br /> 10.Comalnera Duantlb ".Not. <br /> Faciii 'S Pttonc: F _ 10 Number. <br /> Pra er 5N Name,Hazard Crass N0. Type <br /> 98, gb,uS.DOT Deaalpti0n lindudlnp P 1 ,�J <br /> and PWAP9 Group(lt any)) i 1 t. . . <br /> HM � � <br /> 1 ckxs."W�A*tg:3npd(F'iuriwrr Msw<i huu,�daa+'+ ti:a�v. <br /> „r l�rx+r ltCiii�.Fi+rlaaa ,•; <br /> aF yl�'�rtiel •K,. <br /> 2 <br /> C7 <br /> 3. <br /> 4, <br /> 1 .5 octal Handling stru0ons and Additional I orrmat on <br /> FWdwsLobe 40tr I.rm"toi dridkk-0 pp(4 f"R t71 <br /> 9b I t 40'25'119-W I y( C;moi, (l <br /> r shippingname.alb an daesl9ed.Padtagad, <br /> er condition nor trenaport accordirrg Io applicable International and national govemmemal regulations.If export shipment and I am the Pr maty <br /> 15. GENERATOR'87OFFEROIt'8 CEICTIf1CAT1 N: I hereby declare that the contents-;,,;of this connment era fully end accurately descnbed above by the ProPe <br /> marked and labeledlplacarded.and are In all respects in Prop <br /> enerator)or(b)(41 am a small quant ty generator)is true. o y ay Year <br /> Exporter,I ceNfy that the contents Of this ignment conform to the terms of the attached EPA Acknowledgment of Consent. <br /> �fy Tat the waste mtnimizadon statement Identified In 40 CFR 292.27(a1(If I am s tangs quemUb Signature 1 <br /> Goner torsfOfferofa Printedfryped Name <br /> i _j .Intamatbnal hipmenisImport�0 U.S. ❑Export from U.S Port of entrylWt <br /> Ll DA leaving U.S: <br /> = Transporter signature(for exports only): <br /> cc 17.Transporter Acknoytedgment of Receipt of Makals I Mpfr�1 Day Y�r <br /> Transporter l PrintedfTyped Name SI �� �F, I 1 r <br /> Z -Transporter 2 PrintadrTyped Name signature Month Day Year <br /> 18,Discrepancy <br /> 18a.Discrepancy Indication Space <br /> ❑ entity ❑Type ❑Residue ❑Partial Rejection ❑FuN Rejectlon <br /> Manifest Reference Number. <br /> 18b,Altemete FaciNty(or Generator) U.S.EPA ID Number <br /> V <br /> Facility's Phone: <br /> ?Be.Signature of Altornate Fecl (or Generator) <br /> Month Day Year <br /> 19.Hazardous Waft Report Management Method Codes(i.e.,codes for hazardous waste trsatmen <br /> lu t.dlSposat,and recycling systems) <br /> o f 2. 3. <br /> 1. <br /> 20.Designated Facility Owner or Operator:CoMfibebon of receipt of hazardous materials covered by the manhat except as noted in Item lea <br /> Prints ped Name <br /> ature a. <br />