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Please print or type.(Form designed for use on elite(12-pitch)typewriter.) Form Approved.OMB No,2050-0039 <br /> UNIFORM HAZARDOUS 1,Generator ID Number ,n rs,rrc ray,} 2.Page l of 3Erre{gq�Fy RFspf pas Phone., 4 Manifest Tracking Number <br /> ii; -. 005-7426058 <br /> q <br /> WASTE MANIFEST : 0 y0 7 4 60'5 8 SKS S <br /> 5 Generator's Name and Marling Address Gener fors Site Address(if different than marling sharess) C� 47 n <br /> ` c7.4'"Tt`rl ik5 )1 faj5 1., . 07%15. - - ai <br /> — <br /> TT „i. r'i&) Vit)_ CfM1i <br /> 31'Y9:14"I'Chi CA 9"5206 <br /> Generators Phone: oQ17 ; t �._ra r rJ7 �- . . " <br /> 6 Tra,e oddeeAQo ayM o .,r u r <br /> ...rw _ ; 7f . r.:,r. '_"1( , U.S.EPA ID Number <br /> 7 Transporter 2 Company Name U.S.EPA ID Number <br /> B.Designated Faculty Name and Site Address 2;fiF JJC ( I1_f ;?3IETA c3 ("6r. U.S.EPA ID Number <br /> Lir "N;11ifi :f:r :a? <br /> Facility's Phone: <br /> 91 9b.U.S.DOT Description(Including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12,Unit <br /> HM and Packing Group(if any)) No. Type Quantity Wf.Nol. 13.Waste Codes <br /> hJl7At^iP i t9P d d r Fk%, i}?JS} VP' <br /> z 2 Nlufff-•-RCRA in}'AR001 Isv i c , I, QU:I, <br /> .(] VJ�'A. t..lJh/v� T i'f p fbe <br /> • .11._x.d.:M13r i� <br /> r..rl <br /> 3. <br /> 4 <br /> 14 Special Handling Instructions and Additional Information ( �,;}.; ;,„!;¢i <br /> 24 Aw ° lr- 1, rrr. <br /> H1Ei 4f Ra "fLtrA `c'ri ' s•Y `r .la ifi FSCu. .1,N k.k'S�. I.. ;s k;3`a ( .Alii":C( r.. '#ini <br /> 15 GENERATOR'SIOFFEROR S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by the proper shipping name,arid are classified,packaged <br /> marked and labeledlplacarded,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 /> Exporter I certify that the contents of this consignment conform to the terms of the attached EPA Acknowledgment of Consent <br /> I readily that the waste minimization statement Identified in 40 CFR 26227(a)(if I am alarge quantity generator)or(b)(ifI am a small qua0tity generator)is true. <br /> GoneratorslOfferors PnntedFryped Name Signature / !- Mo h Da YeF - <br /> Y9 <br /> =r 16.Injormalonal Shipments El - p <br /> Import to U 5 ❑E$pprt from ll 5: Pqd of en(lylekih _ <br /> z Trensponef signature(for ezpMe duly) *•* Date laay'i`g U,S, <br /> Lot 17;TranspoherAcknowledgment of Receipt of Materials - <br /> �. Than <br /> O oFo or 1 Printed yped Name - Signature F <br /> i J\ t M�} - _ Month Day c Year <br /> - d Transpeder 2 r.tedIT ped Name , Signature -- Month Day Year <br /> / <br /> T15.Discrepancy - <br /> 18a Discrepancy Indication Space ❑ Quantity Type Residue ❑Partial Rejection <br /> on LJ Full Rejection <br /> Mamfds Reference Number <br /> 181 Alternate Facility(or Generator) U.S.EPA ID Number <br /> J <br /> U <br /> LL Facility's Phone: <br /> put 18c.Signature of Alternate Facility(or Generator) Month Day Year <br /> Q <br /> Z <br /> N19.Hazardous Waste Repel Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> 1. <br /> 20.Designated Facility OWneror Operator Certlfieation ofreceipl of hazardous materials covered by the iramfesf`excepl as noted in Item 18a <br /> P_dnledLTvped""ame SignatKre r Month Da;' Year <br /> EP�A�Fq'r p7�0 2 (Rau 05) Preyiqud tfgn� ,e g�so�etg. . <br /> dESIUNATEPrFACILITYTC7GENFGiATUR <br />