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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 WASTE MANIFEST o 3 0 Q � I i3g7q T3 -2=b 0 003741035 GBF 5. Generator's Name and Mailing Address ��^ �+, Generators Site Address (11 different than mailing `address) nn 0t k'®1ZK✓ 7a e s� CJO 1 �r �` �, P �- loan t p L� W tiu , Fot+z i�u - oS `�U+_ `Wk) / CPIV , 0 O� Generators Phone: 2k to q 6. Transporter 1 Company Name U.S. EPA ID Number 7, Transporter 2 Company Name U.S. EPA ID Number 8. Desiggateti Faci"" me and itlity aeAddress � U.S. EPA ID Number j its Facility's Phone: ga• 9b. U.S. DOT Description (Including Proper Shipping Name, Hazard Class, ID Number, 10, Containers 11 . Total 12. Unit 13. Waste Codes HM and Packing Group (if any)) No. Type Quantity WtJVoi. No " (ZCfaps jW244vvas t LLI 2. � @� t°� � 11S �t � tb��l . a � C) q © tom Mr le 01 J 4. S fat H ndling in tructions a d Additional Information f INC"l� � • lst��- Cl �� r-� 34 '2 59/01V?104 4 O54�3 -tai- CI vt 1 flr� 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, marked and labetedlplacarded, 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 Exporter, I certify that the contents of this consignment conform to the terms of the attached EPA Acknowledgment of Consent. I certify that the waste minimization stat ment i i mitred in 40 CFR 262.27 a) Qf I a rge quantity generator) or (b) (if I am a small quantity generator) Is true. kGMneiator ffeerorr's Printed/typed Name sin Month Day Year mo) Yj _t i6. International Shipments t— ❑ import to U.S. ❑ Export from U.S, Port of entrylexit: Transportersignature (for exports only): Date leaving U.S.: 17. TransporterAcknowledgment of Receipt ofMatedals Transporter 1 Printed/Typed Name Signature Month Day Year d Transporter 2 Pdntedrryped Name Signature Month Day Year F 18. Discrepancy 18a. Discrepancy Indication Space ❑ Partial Re ❑ Full Re ❑ Quantity � � � � �'I ❑ Residue Rejection )action lee u 1 Manifest Reference Number.. 18b. Alternate Facility (or Generator) A N f U 19 U.S. EPA ID Number :3 Jv Facility's Phone: C W 18c. Signature of Alternate Facility (or Generator) r t — Month Day Year gfl C� 3 is : p'sS A` � I us 19. Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste treatment, disposal, and recycling systems) 0 1 . 2, 3. 4. i 20 Designated Facility Qemer or Operator. Cedifica8on of recelpFof hazardous materials covered by the manifest except as noted In Item 18a PnrxtedJypsd Nave Signature Month Day Year I I `m5 5=rzfRex 3.051 Previous editions are obsoletelee . DIESAG GATED FA ILVTYTO DESTINATION STA;' (IFREQUIRED)