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Please print or type 4 GENERATOR * 1 UNIFORM HAZARDOUS
<br />WASTE MANIFEST
<br />1. Generator ID Number
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<br />2, Page lot
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<br />3. Emergency Response Phone
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<br />4. ManNest
<br />019703957
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<br />Tracking Number
<br />JJK Generator's Name and Mailing Address Genetalor's Site Address (if different than mailing address) ---4N-V-4iA4-!V' >
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<br />I '5 Generator's Phone:‘ ?4,4--"`` 4* i c---4- 1 ''''' 1.1- ...-‘,'
<br />Transporter 1 Company Name U.S. EPA ID Number
<br />I C-(4-›-5c‘.A.- ?-9 `) 7. Twspbder 2 pany Name U.S. EPA ID Number . i t` t
<br />-Itl..,i ) L4,,-1( I CM e i q 1 tti Designated FacibiName and Site Address U.S. EPA ID Number
<br />C._ V.- :24,.Z:71
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<br />Facility's Phone: (5%.1..)11-S -z.- • 544 5- I
<br />9a. 9b. U.S. DOT Description (including Proper Shipping Name, Hazard Class, ID Number, 10. Containers 11. Total 12. Unit
<br />HM arid Packing Group (if any)) No. Type Quantity Wt.Nol. 13 Waste Codes
<br />5-TE 1
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<br />WASTE WA S RECEIVE)" I Li Nr........% AND
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<br />DISPOSAL. TREATMENT (.)14 khl Sa CRUS . euxkirrs otANTED TO 13 at oVEXE0N. INC, lum 1SY
<br />.81r Del ."1.",w'r-t'n sir i opERA-rEs 1.} A' rri I DIE ENVIRONNOWTAI, PRO171 _.Lik.PARTASENT OF TOXIC SUBSTANCE Cr':' 11 (E. REsouRcE rovkl I loici.NctA3Gvt-N. cy IN iiCanzn oje6 wrru , 7732.N
<br />mi-Aoci_usry t!,,DE.,
<br />-Hio--vroGr- hire 4 '11x1F.R.AL A ND STATE REGIII_ATIONS. CR0%8E-RV Y&ACT
<br /> UF 1976 TOceritut FAMTTS ro A CcrpT iit.E 1,z04.),LF.t4(11) wA OVCRTON RA 5 ALL of ' "-Oki) Dia.
<br />. wmf 4PrtLsi°k'N A Tif, NrFer c °F B LE y AND ALI. THE WA STE NA 5 . C li FEN INA Ntl. '" Fr
<br />1 4. Special Handling Instructions and Additional Information Dt-N.-Vv A, j '6),,,. %,..) C +4-11,... r 0,-...,,
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<br />15, GENERATOR'S/OFFEROR'S CERTIFICATION:. I hereby declare that the contents of this consignment are fully and accurately described above by the proper shipping name, ard 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 that the waste minimization statement identified In 40 CFR 26227(a) (if I am a large quantity generator) or (b) (ill am a small quantity generater) is true.
<br />Generatoes/Offmor's Pnnted!Typed Name Riiattfre- Month Day Year
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<br />16 International Shipmentsn LII -, -......._., Import to U.S. Export from U.S. Port of entry/exit:
<br />Transporter signature (for exports only): Date leaving U.S.: TRANSPORTER 17. Transporter Acknowledgment of Receipt of Materials
<br />Transporter 1 Printed/Typed Name S4naturev Month Day Year
<br />\ k 1 -VI. )A I t \ I \^' H -t I 1 t Transp 2 Printed/Typed Name . A Signature \\......... Month Day Year •
<br />A..... lag 1 .11 I 2- ( 1 DESIGNATED FACILITY -÷ i ( 18. Discrepancy'
<br />Discrepancy Indication Space Quantity LIType III
<br />Manifest
<br />Residue El Partial Rejection EliFull Rejection
<br />Reference Number:
<br />Alternate Facility (or Generator) U.S EPA ID Number
<br />Facility's Phone I Signature &Alternate Facility (or Generator) Month Day Year
<br />I I
<br />19. Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste treatment, disposal, and recycling systems)
<br />1
<br />il q 1
<br />2.
<br />fli 11 )
<br />3. 4.
<br />20. Desig ated Facility Owner or Operator: Certification of receipt of hazardous materials covered by the manifest except as sided in Item 18a
<br />Printeclayped Name Month Day Year
<br />%A i/v1 I A, . - -
<br />orm eV.Previous edifions a4re obsolete. DESIGNATED FACILITYTO GENERATOR
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