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f <br /> F <br /> of acknomedges Gemwthat no fit wmr qe f4� and etther In M ctu lws ix In puss gettet9 9 tial. <br /> Form Approved.OMB No.2D5Q- 9 <br /> F Ike,e print or type. <br /> UNIFORM HAZARDOUS GAn t�{`IID13u�ibg> 8 5 9 9� rtift <br /> 2.Sage 1 of 3 �cS4�f3� �Ma0 1 4 t�N5 2 5©`T F�.E <br /> WASTE MANIFEST t+C ?V 3G 1 <br /> Gi rent than mailing address) } <br /> 0 Wen Vernaks Road SAME <br /> Tom.CA 9W77 <br /> Generator's Phone 14 2BZ aS77 <br /> 6.Transporter 1 Company Name U,&EPA ID Number <br /> G an Harbors Eftir�r�l s.lntc. M A U 9 _2 2 5-0 <br /> 3 <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> a. gn�ated.Facility Name and Site Ad#rr w U,S.EPA ID Numt er } <br /> 15k <br /> k2;9WqnA"* <br /> �r�E�1�• 94351 <br /> Faciih mono: <br /> ga 9b.U.S.DOT Desoription(induding Proper Shipping Nam,Hazard Gags,ID Number, 10.Containers 11.Total 12,Unit 13.Weste codes <br /> M and Packing croup(Ir any)) No. Type a WINo1. <br /> 1 i 1 <br /> •If t[Stf�ll _ - <br /> c <br /> 2 <br /> "LOW 0<)i IDC- <br /> m.3. <br /> 4. <br /> 11 tructions and on '3y—FT <br /> 2-=401" <br /> fit. er to OF�e ad mal tr�kfS on b � C0f9 - <br /> m, i <br /> :15. GEN ItATE1R'SFt3F:� ORIS MTiFWRTItiEd:I hereby declare that the conthnts of this conslgnmeni are tiny at accwa*dewlbed above by"properstri PkV naive,apt ene loss 1,padm* <br /> marked and labetelMacarded,and are in all respects in proper condition for transport according to applicable internacional and national govemmental regtriatians.a export shipmeritand I an the Primary <br /> Exporter;l certify that the contents of this consignment confvmr to the terms of the attached EPAAduvwtedgment of Consentg <br /> I certify that dw,waste minimization statement ident fled in 40 CFR 262,27(a)(if I am a large quantity genera8or)or @)(if small tits gene is true. <br /> GeslOffero s PrintedlT' i I Carrie S gnature Montle Dap V r <br /> 1 <br /> 1B. of adw'.it <br /> Import th U.S. ❑Fxpart from U.S. Dai leaving U.S.: <br /> ? Transporter signaturo{(ig'gg ,y mly):: <br /> GC 17.Transporter Acknowiedgmekoff'receiptoffAatetiats <br /> LAJ_g: Transpo 1 PrintedlTyped Name .: Signature M®nat y yew <br /> C. <br /> z Transporter 2 Prtn 'Eryped Name SignatL6 Month Day Year <br /> 4', <br /> 18.Discrepancy <br /> 1Be,Discrepancy Indication Space ❑ Quantity ❑Type ❑Residue ❑Partial Rejection ❑Full Rejection <br /> Manifest Reference Number. <br /> t: 18b.Atternate Facility(or Generator) U.S.EPA ID Number <br /> .i <br /> Li <br /> Ci Facility's Phone: Month Day Year <br /> w 18c.Signature of Alternate Facility(or Generator) <br /> 3: <br /> vr, e <br /> 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systms) <br /> Gi 1• �� L { {� 3' 4. <br /> 20.Designated Facilityer r Operator.Certification of receipt pf hazardous materials covered by the manifest except as noted in Item 18a <br /> PrinIM/Typed Name Signature Month k4 L�1" I I --? QRay Year <br /> V <br /> IPPA Fo!CIjffflqfjdj&S IW WHI accept the waste Me generator Is s ISNATED FACfVT�j i AN1FEST"WM <br />