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Please print or type.(Form.designed for use on elite{12-pitch}typewriter.) Form Approved.OMB No.2050.0039. <br /> UNIFORM HAZARDOUS 1.Generator IQ Number2.Page 1 of 3.Emergency Response Phone J <br /> ,Maniftst Tracking Number <br /> WASTE MANIFEST 2:t.OU Vit. ] r ftt- :�f�? ° .� 4� d JJ K <br /> Generators Name and Maigrrg Address ` Generator's Site Address(•d different than matting address). <br /> • r ��M �{E4���'�fl�^a .-.i..._. ... :•':.i-�s:s.. .i iAa•s-�! st ,: �'r 3r= <br /> 41;pc4h 00 <br /> t...r711'MR CA �7���rr -A!1 tff!! /� <br /> 7itj..�'• f�r-•+f il�.l.t - , ' - <br /> Generator's Phone:: <br /> 6.Transporter 1 Company Name U.S.EPA la Number <br /> �.r'.'y]{�f'�t�£1�Pd�:��'�SSi:°�",YP�rff'E:�'."- �r�?:: i.,�`•.€'ii��ci1.���`"s'� <br /> 7.Transporter 2 Company Name U.S.EPA IQ Number <br /> B.Designated Facility Name and Site Address ,, <br /> Fps by$Ova R ir1:fflC U.S.EPA 1D Number <br /> L i31L �C�2. <br /> .A 491 e <br /> Facility's Phone: <br /> 9a. i 9b-U.S.DOT Description(including Proper Shipping Name,Hazard Ctass,IQ Number, 10.Containers 11,Total f2:Unit 13.lAPdste Codes <br /> HM and Paddng Group(if any)) No. . Type Quantity WtNol. <br /> let - <br /> 2 2. <br /> tA.i <br /> 3. ! <br /> 4. I ' <br /> 2 l <br /> i.Sped@I li <br /> Handng knss and AdditywtaInmon <br /> truclicnf Faratl <br /> :� dk5i7;Fu.r:Y- f'Ar''1NIi0fk�GM. tilrtgi R4: <br /> 15, GENERATOR`SfOFFEROR!S CERTtfICATION: I hereby declare that the contents of ttds consignment are fully and accurately described above by the pmpar shipping naive,and are classified,packaged, <br /> marked and labeledlplacarded,and are in ail respects in proper condition for transport aocarding to applicable international and national governmental regulations.If export shipment and I am the Primary <br /> Exporter,I cartify that the contents of this consignment conform to the terms of the alladled EPAAekrwwiedgmerd of Consent <br /> 1 certify that the Waste minimization statement identified in 40 GFR 262.27(a)(g 1 am a targe quantity generator)or(b)(If l am a small quantity gsneratoo is hue. <br /> GeneratorslD#feraes'NntedfTyped Name signature Month Day Yeaf <br /> -j 16.International Shipments w._.. , <br /> r- Qlmport to U.S. ❑Export from U.S. Port of en exit: <br /> 2 Transporter signature(for exports only): Date leaving U.S.: <br /> W 17.Transporter Admowledgment of Receipt of Materials r <br /> Transporter 1 Printed)Typed Name};; Signature 7 Month Day <br /> Year-Transporter 2 PdntWyped Name Signature Month ' Day Year <br /> f1' <br /> H <br /> 18.Discrepancy <br /> 186.Discrepancy Indlcation Space ❑ Ouanilty LI-type ❑Residue 0 Partial Ra]ecrien ❑Full ReJWUon <br /> Manifest Reference NumbEr, <br /> 181o.Altemate Fac&y(or Generator] U.S.EPA ID NuTUr <br /> is <br /> Faci[iVs Phena. <br /> 18c.S gnature of Altamate Facility(o;Gene Month Day Year <br /> a <br /> T <br /> Hazardous Waste Report Management Method Codes(ie..codes for hmardous waste treatment,disposal,and moycHng systems) <br /> p 2. 3. 4. <br /> Zip-Designated Facility turner or Operator.Certification of receipt of hazardous materials covered by the mafufestexcept as noted in Item 18a <br /> PrintRYpeci Name Signature - Month Day Year <br /> EPA Forel&700-a2(Rev.3-05) Previous editions are obsolete. 7RANSPORTER'S COPY <br />