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Generator acknowledges that no►nifedal change has oct:wed either In the charaotedstics or In the process general the matertai. <br /> Please print or type. I� <br /> UNIFORM HAZARDOUS 1.Generator 1D Number Form Approved.�OMIBNo.2050-0039 <br /> A!-0 0,0 41.Q�6 9�. 2.Page 1 of 3.Emergency Response Phone 4.Manifest Trackin NumberWASTE MANIFEST 1 (800)4133-37 ,8- 1Mai Adress 014 5-2 6 5L.,E <br /> K Urfiei,!nc enerator's Site Address(it different than rrtaAing address} <br /> 0917 KM <br /> cerie�ators Pnone A 4fi:7340 <br /> 8.Transporter 1 Company Name <br /> Clean Harbors.E U.S.EPA ID Number <br /> rwgror+rrterstal3erYiales„I MAD 0 3 9 3 2 2 2,5 0 <br /> 7.Transporter 2 Company Name ,<. »: <br /> U.S.EPA ID Number <br /> 8.Designated Facility Name and Site Address <br /> Clean H wbgrS Aw U.S.EPA ID Number <br /> LLC. , <br /> 11$08 NeftAanfRoatlN T O 9 81 5 5 21 7 7 <br /> Facility's Phone: <br /> ga 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,10 Number, 10.Containers it.Total 12.Unit <br /> HM and Packing <br /> Group(if army)))) No. T auffillity ftw 13,Waste Codes <br /> P PE DE TYK F...UM®.: <br /> x. (PEROXYACETIC <br /> W o o L I>f- 061.0 P <br /> 2. <br /> �" . . '-° :,R;i`� alt' ,i J-:- k,.2i, �-✓. <br /> 4. <br /> 1�St�fffiliud,Irjjctionsand aLlafjgti6n <br /> .. ZZUU ZZ''!!'f� JiliS <br /> WWANN <br /> r,01`140181 ftMM*0fI tO WY or,rl' •' ,f t� f �Y .try/�q pulws awls <br /> 15. GENERATOR'SIOFFEROR'S CERTIFICATION. I hemb declare that the contents of this oorisl ment are fu and aeaxate scn abo'v>r& e <br /> g tiY l Y Proper shipping naK6,'aid are classr ed,p aqe , <br /> marked and iabeledlplacarded,and are in all respects in proper condition for transport according to applicable intemalionaf and national govemmentat regulations.H export shipment and I am the Primary <br /> Exporter,I certify that the contents of this consignment cordorm 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)(it I am a large quantity,gen(ptor)or(b)(if f am a sr6fl quantity nerator 's We. <br /> Generator's/ or rintedrryped Name Signature Month Day Year <br /> 14n:� C. I I I IZ <br /> 16.International Shipments <br /> FLJ Import to U.S. ❑Export from U`S. Port of entrylexit: <br /> Z Transporter signature(for exports only): Date leaving U.S.: <br /> it <br /> W 17.Transporter Acknowledgment of Receipt of Materials <br /> Transporter 1 Printed/Typed Name Signature Month Day Year <br /> o (�k U ti ZO <br /> a <br /> Z Transporter 2 Printedityped Name Signature Month Day Year <br /> .r- <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space <br /> Quantity ❑Type E]Residue ❑Partial Rejection ❑Full Rejection <br /> Manifest Reference Number. <br /> IZ 18b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> J <br /> U <br /> Facifity's Phone: <br /> H18c.Signature of Alternate Facility(or Generator) Month Day Year <br /> R <br /> Z <br /> 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> LLJ 4 1 . H040 2. 3. 4. <br /> NQ40., <br /> 20.Designated Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a <br /> Printedfi ped ame Signature 9 Monr �th �fDay �Yea�r <br /> t P p� Y�P 11� , 13 1 <br /> Gl/ <br /> PA For���RO b7�@rid S Pyre� mTH576r�nd 1W1 accent tM .,MMGNA ACILITY TO EPA's e-MANIFFST SYSTFM <br />