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is 4, 1 or I <br /> Please print or type.(For(n designed for use on Ilite 12-pitch)lypeWriter.) Form Approved.OMB No.2050.0039 <br /> 1.Generator ID tuber �� 1 t 2.Pegz t of 3i Err4(9g�yRe�sp'pseP.)o�el� 4,Ma rfe tTr eking Num ar <br /> UNIFORM HAZARDOUS i;¢}i,., k_=:1,.,t :..: a 3 274 <br /> WASTE MANIFEST <br /> S.GeneretofsNamaan ailing Address Generator's SRO Address(ifdifferent than mailing address) <br /> AIM,.;lf;f1';; -- `:!-1���:1i':gti.`-! ;al}TfJ.ZONE <br /> P t S„:r z AT;d MuI. <br /> tt r'L13 !,v::9 n 6i.11T! i <br /> I��I"Y��ilT:"� }•I�.{ _3�}.`-��"i_..ri; .'1� r1r.��.tt ��i•y��..:� <br /> 9_.0 di 3:1��, n d 01r,V7 0IN <br /> Generators Phone: �”:. " <br /> 6. s�gtt 3. lnflmlyll�me_ r U.S.EPA ID NumberID 91 101 F <br /> 7,Transporter 2Ccmpany Name U.S.EPA ID Number <br /> 8.Designated Facility Name and Site Address UB ECOLOGY Wfth;tri U.S.EPA ID Number <br /> BEAT TV 9 i1fr,3 <br /> }_r��_-?{-lt}� fL�f i„•�$�{till i' ''S/1S: <br /> Facilit s Phono: <br /> ga 9b.U.S.DOT Description(induding Prope 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 YVLNol. <br /> 1. I ,e R C. N U'} fiurir Si! ' 1 rG w Rill a'.Ci :2,r P <br /> z 2. <br /> U3 <br /> 3. <br /> 4 <br /> 4. <br /> 14.SpecialHandling tnsl actions endAdditlonat InfOrmallon S(; 9111r;rl: ,r 1 <br /> 0 070140600-360 <br /> 15. GENERATOR'S10FFEROR'S CERTIFICATI N; 1 hereby declare that the contents of Sus consignment are fully and accurately described above by the proper shipping name,and are cassiliad,packaged, <br /> marked and Iabeledfpllacarded,and are In all epecis in proper condition fortranspprt according to applicalde intemalional and national governmental regulations.If export shipment and I am the Primary <br /> E)Toner,I cert fl-thatihe contents of 1'nis con ignment conform to the terms of the attached EPA Acknowledgment of Consent. <br /> I certify that No waste minimization stalemen identified in 40 CFR 282.27(a)(if I am a largo quantity generator)or(b)('d 1 am a small quantity generator)is true, <br /> Month ay ear <br /> Generator's'Offerora PrintedlTyped Name ,gna ure <br /> 1(571 <br /> J 16.International Shipments _�. <br /> F LJ Import a U'S. ❑Export from U.S. Port of entrylexit — <br /> Transporle ' lure,for exports avin us- <br /> LL, <br /> ITT sporlerAcknovAedgmenlofRe ptofWle'als <br /> Tra rter 1 PnnledrTyped Name nal on mo�rray ear <br /> � <br /> M <br /> 16.E 1 <br /> a /'' � Month Day ear <br /> dTransporter 2 n yped Name' ,gnalure <br /> 18.Discrepancy <br /> 18a.Discrepancy I,ndicatfon Space ❑ Qua IV ❑Type ❑Residue ❑Partial Rejection ❑Full Rejection <br /> 6fanifesf Referen Number. -_� <br /> 18b,Alternate Facility(or Genarator) U.S.FPA ID Number <br /> U <br /> LL Fdhunee <br /> f Aemate Facility(or Generator) Month Day Yoar <br /> w1 <br /> d <br /> z <br /> N19.Hazardous Waste Repot Ma e t Method Podes(Le.,codes for hazardous waste treatment,disposal,and recycl ng systems) <br /> 20.Designated Fa ity Oa' or Operator.Ce o ei ft of hazardous m� rials covered by the manifest except as not in llem 18a <br /> Printed yped Name Signature t Nh D Y ar <br /> EPA Fog 8TQ.0�2(ttev 05)-Preyi s e ions re o ate. DESIGNATED FACILITY Tt3 DESTINATION STATE(IF REQUIRED) <br />