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A <br /> y <br /> Please print or type.(Form designed for use on elite',(12•pitch)typewriterftj ,, t``EQ T7,r 1s°s;'s 4}-: "� r': `a w Form Approved;OMB No.2050.0039 <br /> UNIFORM HAZARDOUS 1,Generator ID Number 2.Page 1 of 3.Emergency Response one 4.ManlFest Tracking Number <br /> WASTE MANIFEST r. t rt " o 0�a� ' ryr. F L E <br /> r as P t, a S f�nn': �'-h <br /> 5.Generator's Name and Mailing Address' Generator's Sil€Addri 's(fdiflerent.than mating address) <br /> ` 1>r> ;Trayet ( z x y+37 '` i ? l +R f..l!:a <br /> N,n rra1we!'— 9 e S i.e. -5,00S.�.�##`sas a <br /> Gg�efa 0r 'Ph6ne� err ky A <br /> 6:Transporter 1 Company Name, U.S.EPA ID Number <br /> !?ter $s i`t,d; 'C' •�ra .fi; <br /> :, <br /> 7.Transporter 2 Company Name U.S.ERATO tff mber" <br /> 8.Designated <br /> Facility Name and Site Address U.S.EPA ID Number <br /> " 9 3 :_,0 <br /> ga. ' .9b.'U.S.DOT Descript on including Proper Shipping Name,Hazard Class,ID Number,-: 10.Containers 11.Tolal 12:Unit <br /> HM and Packing Group(if any)) No Type quantity VbVOI. 13.Waste Codes <br /> t��,�_{� 7 y ::<+t_. f• ?r. �1 � f <br /> W,AST E,a! LZ6J.�' oA -•i:L <br /> a TNTA€�1.NATE$3 Slryl <br /> LU 2. - <br /> 4. <br /> i <br /> i <br /> 14.Special Handling Instructions and Additional Information <br /> 15. GENERATOR'SIOFFEROR'S.CERTIFICATION: I hereby declare that the contents of$t.cornsfgn cent arefglly aod.accurately described above by the proper shipping name,and are classified,packaged, <br /> marked and labeledlplacarded,and are in all.respects in proper condition for transprding to applicable international and national governmental regulations.It export shipment and I am the Primary <br /> Exporter,I certify that the contents of this consignment conform to the terms of thea, ed EPAAcknowledgment of Consent. <br /> I certify that the waste minimization statement identified in 40 CFR 262.27(a)(if I.am.a large quantity generator)or(b)(it I am a small quantity generator)is true. <br /> eoera�sl erors not ypfe ane l _ Signature on ay Year,: <br /> ;f r"7J .�? l_ —� ✓�-��- n,.s_.� �ttvi <br /> J 16.Intematlonal Shipments ' - "� <br /> E]Importto U.S. ElExportfrom�U.S. Port of entry/exit <br /> Transporter signature(for exports only): = Dale leaving U.S.: <br /> w 17.Transporter Acknowledgment of Receipt of Materials Gi <br /> *nsporter 1 Printed/Typed Name., ! \`Signature Month DX Year <br /> VIL <br /> z Transporter 2 Printed/Typed Name Signature W_ Month Day Year <br /> r- <br /> 18.Discrepancy <br /> 18a.D' epancy Indication Space .,, ❑ yP` ❑ ❑ I a i <br /> .� ❑ QuantityT e Residue Partial Re'eclion Full Rejection ,• <br /> Manifest Reference Number: <br /> 18b.Allemak Facility(or Generator) U.S.EPIt'Ib Number <br /> J <br /> U <br /> a <br /> Facili sfhone: Oar <br /> Ow 16c.Signature of Altemale Facility(or Generator) Month Day. Year <br /> Q - <br /> Z <br /> ,19.HA'de Waste Re rt Ma gevjn nil Mefhod.Codes p,e:,codes for}razardous` asle beabnent,disposal,and recycling systems) <br /> 2 - 3 .4. <br /> c '1 Fye( • ��; <br /> t <br /> 20.Designated Facility Own r or Operator Ce6 *on of receipt of hazardous malenals covered by the manifest except as.noledan Ile '18a <br /> Pnnted/Typed pme / Sign fe / �:" Month D�ye�c, <br /> EPA Farm 8700-(Rev.M5)•Ft'revious editions'are gtisolete. fi DESIGNATED FACILITY TO GENERATOR <br /> } s 1>?�is <br /> HA-m m st sg nasty y t :iii+?P?-F, �T r�1'? G& t .a� p y' 4 ' ' <br />