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Please ,rint or type,(Form designed for use on elite(12 pitch)typewriter)
<br /> UNIFORM HAZARDOUS 1.Generator lO urn at �c y Form Approved.OMB No.2050-0039
<br /> 1 (Mir�0 d dla,ni f, 2.Pan 1 of 3 E Ig nFy,f� se,tPh neC 44..'gManl(esl Tiacking(N�umber- (� SKS WASTE MANIFEST E .e. t- „+�^.: r� P fw'..f p�1 4.1 0577' lot 860 S KS
<br /> 5 Generator's Name and Mailing Address Generator's Site Address(if dllferenl than mailing address)
<br /> �d 'Tran , 'ai'tq .t X',) 4rPld ( W. .
<br /> I fid)l ' ( t>9 rAr�m"ICs IJ,tbR;l,
<br /> Generalprs Phone 4�L�rx? :s-�3. afxn�u)' _ -
<br /> 6 Tra P de. Co a Y me `;<i
<br /> 7 i � � U.S,EPA ID Number
<br /> `7 Transporter 2 Company Name UIMP P ID Number
<br /> B De519naled Faclhty Name and;Site Addres's .IHS; yrj'[j T Il l{T IJZ'is U.S.EPAID Numher
<br /> 1'Jey M1. W JEF c g1.0, l014 ti'G
<br /> F'PdU�hd1.Y, � ';"i: ztfSLta(<k'
<br /> sten Y;0, rk>61r
<br /> Facility's Phone: �
<br /> ga, gle.UB.OCT Description(including Proper Shipping Name,Hazard Class,ID Number, 1DContainers -
<br /> HM and Packing Group(if any)J . 11.Total 12.Unit 13.Waste Codes
<br /> No, Type Quantity WI.Nol.
<br /> iVC1lV-4,.Cf�� !&A h�E�Eb S"{S4� TC tir)1TSS , r
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<br /> 14.Special Handling,Instruclions and Additional Information -;',,,It '1'I ! ..5'' VVI 1{:., (,T,y-77 cM zny js r r ,I,t
<br /> rt,[ a �3 t> a,art i76", r ,14
<br /> r[1{II AY:k r�Txk.I4T—$"(1}i" BY rxti4 Y'.3 .v'i. Pftbq �.. [cr frt ?'S klrEi C, r:c<) ,{,; Kl„ Ilt1.,t :>tid4f '
<br /> 15. GENERATOR'SIOFFEROR'S CERTIFICATION: I hereby declare that the conlenls of this consignment are fully and.accurately described above by the proper shipping name,and are classified,packaged,
<br /> marked and labgled/placarded,and are in all respects in proper condition for transport according to applicable international and national.governmental regulations.If export shipment and I am the Primary
<br /> Expeller,1,certtfy,that the conlenls of this consignment conform to the terms of the attached EPA Acknowledgment of Cpnsent. -
<br /> I rectify,the t the waste minimization statement idenlifed in 40 CFR 26227(a)(if I am a Targe quantity generator)or(b)(iII am a small
<br /> , qujant�it!y generator)is true.
<br /> Generators/Oefor's PrtedTyped Nee Signature
<br /> Month Day Year
<br /> 16,International Shipments .
<br /> } z ❑Import to U.S. LJ Extend from U.S. Pad of ent4/exit:
<br /> Transporter signature(far exports only): Dale leaving U.S.:
<br /> w17.Transporter Acknowledgment of Receipt of Materials - -
<br /> y Tyan`spgrler 1 P�Jx
<br /> Signalurei r.. Month Day Year
<br /> C Transporter 2,P —` Signature ''"/ Month Day Year
<br /> 18.Discrepancy nr
<br /> Yf/
<br /> 18a.Discrepancy Indic alion Space ❑ Quantity Type ❑Residue ❑Partial Rejection ❑Full Rejection
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<br /> 186.Alternate Facility(or Generator) - - Manifest Refereliice,Number, U,S.EPA ID Number
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<br /> LL Facility's Phone: -
<br /> 182.Signature of Alternate Facility(or Generator)
<br /> ••��- - Month Day Year
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<br /> 19.Hazardous Waste Report Management Method Codes(i-.e.,codes for hazardous waste treatment,disposal,and recycling systems)
<br /> 20.Designated Facility Owner or Operator Certification of receipt of hazardous materials covered by the manifest except as noted in Item 1Be - -
<br /> Prinled/Typell Name �7 Signature ^ f Month
<br /> Day Year
<br /> l I 1 A .-..A X11 e /...
<br /> EPf4.Fo/mB700122�(geA r3� �.Pr�vious editions are obsolete. . DESIGNATED FACILITYTO GEN RATOR
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