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Please print or type. Form Approved.OMB No.2050-0039 UNIFORM HAZARDOUS 1.Generator ID Number 2.Page 1 of962A-61►3(,, ency Response Phone 4.Manifest Tracking Number WASTE MANIFEST �/"(�r —`y� 1. 1 1 019704372 JJ K 5.Generator's Name and Mailing Address eneralors Site Address(if different than mailing address) [,1pn�G'�' r � Il 4y 2q I r`�z�u •�P (A Genera'tofsPhone: rl�) -diALr� 6 sporter 1 Company Name U.S.EPA ID Number 7.Transporter 2 Company Name U.S.EPA ID Number p 8.Designated Facility Name and Site Address U.S.EPA ID Number FacditysPhone 614 \1 "!T32 "JIAA:a 9, 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit F-- Z 13.Waste Codes FIM and Packing Group(if any)) No. Type Quantity Wt.Nol. la� lVvn=��` Nc.�r.-Ydo �nk�y ►` `'0 l VM &Z. w 3. 4. special Handling Instructions and Additional Information /7�0 -'�( wl K, �YG i�rQ,lY1Q�4 A7,6,51 �dwry. rY 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 labeled/placarded,and are in all respects in proper condition for transport according to applicable intemational 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 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 Generators/Offeroe. Printed/Ty d Name _Signature Month Day Year 1 i��l Cr 11ic 16.International Shipments Import to U.S. ❑Export from U.S. Port of entry/exit: — ? Transporter signature(for exports only): Date leaving U.S.: w 17.Transporter Acknowledgment of Receipt of Materials Transporter 1 P'n d/ryped Name Signature .Q Month Day Year O , `/ / ��D a Z Trio ler 2 Pdrited/fyped aa�m q Signature Month Day Year 18.Discrepancy 18a.Discrepancy Indication Space Quantity ❑Type ❑Residue ❑Partial Rejection ❑Full Rejection Manifest Reference Number: 18b.Alternate Facility(or Generator) U.S.EPA ID Number J U Facility's Phone: Month Day Year W 18c.Signature of Alternate Facility(or Generator) Q 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) 0 AZgn�aYFacility 2. Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except as noted In Item a Pdnled/Typed ame Signature Month Day Year e-MANIFEST SYSTEM "0-22 EPA Form87ev.12-17) Previous editions are obsolete. L� SIGN ED FACILITY TO EPA's