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attl_ H rt y "a,0);?02.I rF r Please print or type..(Form designed for use on elite(12-pitch).typewriter.) Form Approved.OMB No.2050-0039 UNIFORM HAZARDOUS 1.Generator ID Number 2.Page 1 of 3 Emergency Response Phone 4.Manifest Tracking Number i Jap{ 31770 L7I1�7 WASTE MANIFEST - Generators Site Address(rfdiffero 5 Generators Name and MailingAddress nt than mailing address) ! rx 'ir :tr, �hoj'y 10 t-c-' ii ' q--f ,x � I I.if,.;`_ - 6 i,`x V I t 1 11)r5 Generator's Phone. x{ V-B i 67'-1,3 6 Transpoder 1 Compan Name U.S.EPAID Number ,r i' i Y..-r LE-.,_If ;aY ,r'L'1`i'x, N'';. 7.Transporter 2 Company Name U.S.EPA ID Number - B,Designated Facility Name and Site Address ;5'A s U.S.EPA ID Number�tt''i0 '1FJ'11H ' 'hi`t,,E.7 1391 z� 1I lk r,t�'fj s Facility's Phone: . ' ' 9, 9b.U.S.DOT Description(Including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit HM and Packing Group(if any)) 13.Waste Codes No. Type Quantity WLNaL 1 131 c-3,kl- Rc('ys`r 4f i lc; YY � Y�A�}r t (tl �' Fl.7�i c.:p {.. Mi.)d.d} Ct W I Z 2 y fj"N- RA HA blie,000S WAS h.J'di1Tf] 0 Yt 3ime �v r ; w'AS;:1 q mS uTICDq 3 r y t 4. 145pecial Handling Instructions and Additional lnformehoo1; 119;4 r ty .It it tit :`( 9180(3 —44 l pp,-N 'Si( <ll'61 Act fif L'<s �_'f...Jl, 13f rit �y )'a P.M Th��jsi �, f n ,.L,. 3 � t .,ui�. � r• . hrr 15. GENERATOR'SIOFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by the proper shipping no me, are classified,packaged, marked and labeledlplacarded,and are in all respects in proper condition for transport according to applicable international and national governmental regUlatlonsr if export shipment and I am.the Primary Exporter,I.certify that the contents of this consignment conform to the farms of the attached EPA Acknowledgment of Consent I certify that the waste minimization statement identified in 40 CFR 262.27(a)(if I am a large quantity gen(uator)or(b)(ifI am a small quantity generator)is true. Generator'aOfferor's Printed/Typed Name - Signature Py i` � Month Day Year ...1 16 International Shipments - -• 1 'z ❑Import to U.S. ❑Export from-U.S. Pod of entryle4F Transporter signature exports only): Date leaving U.S.: _ w 17.Transporter Acknowledgment of Raceipl of Materials . . Tr nob ler 1 Printed/typed me Signature � ✓ ." 0 9 - ) Month Day/ Year y TV Z Transpoder Pn ted/fypehName - Signature 9 Month Day Year j18.Discrepancy 18a.Discrepancy Indication Space ❑ puanti - tY ❑Type ❑Residue ❑Partial Rejection ❑Full Rejection - Manifest Reference Number: 18b.Alternate facility(or Gene rator) � :.'� ---" � ,-U.SrEPA ID Number. J � V L Facility's Phone: - w 18c.Signature of Alternate Facility(or Generator) Month Day Year v Z y19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) p I. 2. 3. 4. 20.Designated Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except as noted in Item Ica - PrintedRyped Name _ Signature Month Day Year ,7 s EPA Form 870022(Rev.305) Previous editions are obsolete. DESIGNATED FACILITYTO GENERATOR