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Please print or type. (Form designed for use on elite (12 -pitch) typewriter:0a ifl5601.4 0M<. SC 1'Pifi! '€.(ii"Form Approved. OMB No. 2050-0039 <br />rrHForm. ts,cuu;;4(rttjyfs;u5);Nrey(4u�,,dinQ ;argrQt leg���5tb� }� will accept gefferalofisdliiftp'iq,.. DESIGNATED FACILITY TOdENERATOR <br />UNIFOftM..HAZARDOUS <br />1. Generator ID Number <br />2 Page 1 of <br />3 Emergency Response Phone 4 <br />Manifest Tracking Nu <br />um <br />WASTE MANIFEST <br />i ` .. ' : t E 4/ ; +t 4 : ' i` <br />6 ." <br />C <br />FLC <br />5. Generator's Name y Marling Address ! Generator's Site Address (if different than mailing address) <br />t [4F'�l15Q;1 Uu <br />ti�rk.t p_ CA K5 Jl 7 ` <br />Generators Phone: <br />T'Transporter 1 ompany Name U.S. EPA ID Number <br />7r�aii tl�rf'f;ftir EO1Vit ?6!lt14}tit>a) %iibfL�$, irlc;. ; �4 !i !d 9 r 0 <br />7. Transporter 2 Company Name U.S. EPA ID Number <br />i <br />8. Designated Facility Name and Site Address U.S. EPA ID Number <br />'`�S1!'iS1,�faiYgV@ R�SGtttRtV i�@C!}°F6'St,` If'iG. <br />t <br />1979Sprint; Greve Avenue y� ii D (i 0 �i! 9 �. `3 i'1 i? <br />'fbwinnwi. Off 45, 232 <br />Facility's Phone: <br />9a <br />9b. U.S. DOT Description (including Proper Shipping Name, Hazard Class, ID Number, <br />10. Containers <br />11. Total <br />12. Unit <br />Waste Codes <br />No. <br />Type <br />HM <br />and Packing Group (if any)) <br />Quantity <br />Wt./Vol.13. <br />� <br />1..MC <br />o <br />tii`i.i;€iUGt)f(5A(AD, Sl11.FAMIC ACID), 9. PO 11 <br />_ <br />z <br />LU <br />2. <br />t_ . _... <br />3. <br />4. <br />1 <br />14. Special Handling Instructions and Additional Information . VILLE. I Nty226 <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, and are classified, packaged, <br />marked and labelediplacarded, and are in all respects in proper condition for transport according to applicable international and national governmental regulations. N 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 certify that the waste minimization statement identified in 40 CFR 262.27(a) (if I am a large quantity generator) or (b) (if I am a small quantity generator) is We. <br />Generators/Offerors PrintedfTyped Name Signature i on ay Year <br />J <br />F•- <br />16. International Shipments <br />Elr� <br />Import to U.S. ElExport from U.S. Port of entrylexit: <br />Z <br />Transporter signature for exports only): Date leaving U.S.: <br />w <br />17. Transporter Acknowledgment of Receipt of Materials _ <br />Transporter 1 PnntedfTyped Name Signature , Month ay Year <br />p <br />CL <br />z <br />Transporter 2 erintedfTyped Name signature r r ,,) Month Day Year <br />} <br />18. Discrepancy <br />18a. Discrepancy Indication Space ❑ <br />Quantity Type ❑Residue ❑ PartiBF Rejection ❑Full Rejection <br />Manifest Reference Number: <br />181b. Alternate Facility (or Generator) U.S. EPA ID Number <br />J <br />U <br />Q <br />LL <br />Facility's Phone: <br />w <br />18c. Signature of Alternate Facility (or Generator) Month Day Year <br />Q <br />z <br />v519. <br />Hazardous Waste Report Managerrtenl Melhod Codes (i.e., codes for hazardous waste treatment, disposal, and recycling systems) <br />p1. <br />: t..: .. <br />2. <br />3. <br />4. <br />r <br />20. Designated Facility Owner or Operator: Certification of receipt of hazardous materials covered by the manifest except as noted In Item 18a <br />Printed/Typed Nomg ( ; r' ? Sigoelure ( r Month Da yf <br />( `! 1. <br />rrHForm. ts,cuu;;4(rttjyfs;u5);Nrey(4u�,,dinQ ;argrQt leg���5tb� }� will accept gefferalofisdliiftp'iq,.. DESIGNATED FACILITY TOdENERATOR <br />