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Please print or type. Form Approved.OMB No.2050-0039 <br /> UNIFORM HAZARDOUS 1.Generator ID Number 2.Page 1 of 3.Emergency Response Phone 4.Manifest Tracking Number <br /> WASTE MANIFEST (�(� C`U G 9 019 7 0 4 0 4 4 JJ K <br /> 5. eralor's Name and Mailing Address Generator's Site Address(if di event than mailing address) <br /> Ge kik'or s PTior�e -J �`/_ _ � K�/ c4 rA <br /> 6.Transporter 1 Company Name U.S.EPA ID Number <br /> .0 L <br /> 7. ions er 2 Company Name OA <br /> U.S. PAI rmber <br /> L i -�t�i-�� )sd r._ c`��c , <br /> 8.Designate ryFacility ame and Sile A d ss U.S.EPA ID Number <br /> -IXogi q D <br /> lbto i ky, sir <br /> Facility's P e: C: Lie <br /> 9a. <br /> 9b.U.S.DOT Descripfioi(including Proper Shipping me <br /> a ,Ifazard Class,ID Number, 10.Containers 11.Total 12.Unit 13.Waste Codes <br /> HM and Packing Group(if any)) No. Type Quantity Wt.Nol. <br /> M 2. <br /> W <br /> 3. <br /> 4. <br /> 14.Special andling Instructions and Additional Inform <br /> I � �Q�� ^-5 <br /> r r F✓v .7 <br /> 15. G E R' OF EROR'S TIFIC : I reby declare that the contents of this consignment are fully and accurately described above by the proper s ipping name,and are classified,packaged, <br /> marked and labeled/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 /> Exporter,I certify that the contents of this consignment conform to the terms of the attached EPA Acknowledgment of Consent. <br /> I certify[hat the waste minimization statement identified in 40 CFR 262.27(a (if I am orge quantity generator)or(b)(if I am a small quantity generator)is we. <br /> Generator'slOfferoes Printed/Typed Name n Qi 4 9 Signature Month Day <br /> Day Year <br /> r✓ ! <br /> 16. n emational Shipments ❑Ex rt from U.S. Port of entrylexit: - -- <br /> ❑Import to U.S. Po <br /> ? Transporter signature(for exports only): Date leaving U.S.: <br /> W 17.Transporter Acknowledgment of Receipt of Materials <br /> LLJTransporter 1 Printedrr d Name Signature Month Day Year <br /> Z Transport 2 Tinted yped Name Signature Month Day Year <br /> cam_ f e lole <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space Quantity ❑Type ❑Residue ❑Partial Rejection ❑Full Rejection <br /> Manifest Reference Number: <br /> U.S.EPA ID Number <br /> 18b.Alternate Facility(or Generator) <br /> J <br /> U <br /> uQ Facility's Phone: Month Day Year <br /> W 18c.Signature of Alternate Facility(or Generator) <br /> Z <br /> y19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> p 1' 2. <br /> 3. 4. <br /> 20.Deai <br /> r or Operator:Certification of receipt of hazy us materials covered by the manifest except as ncted in Item 18a <br /> Printe �` Signature c_ Mo9th Day Year <br /> EPA Formv.12-17) Pre st`ed ons are obsolete. DESIGNATED FA(.'t ITY TO EPA's e-MANIFEST SYSTEM <br />