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�1l III lilt 11111Please print or type. (Form designed for use en elite (12•pitch) lypewntec) TJr-1 -tit- FormAPProved. OMB No. 2050.0039 <br /> UNIFORM HA2.ARDOUS 1 , Generator t0 Number 2. Page 1 of 3. Emergency Response Phone 4. Manifest Tracking Number <br /> WASTE MANIFEST y (. Gi i:;k) G�?; c ;;7 31210922• 204 008570559 FLE <br /> 5. Generators Name and Maifing Address Generators Site Address (il difterenl Than maRing address) <br /> C- 'I5 ( Sls ) # 1636 <br /> 21 ' 13r .n • c28,01 u _ <br /> 72C ( e1s HVcy Erltii , 4 <br /> Generators Phone: irianteC •a . LR 95336 <br /> 6. Transporter 1 Company Name U.S. EPA ID Number <br /> v � ei^ iCriC '� $ &3eE: la1a ' rt)& sae Solutions Inc i:) 17,ft0'1S111171rQ1:1c <br /> 7. Transporter 2 Company Name U.S. EPA ID Number <br /> = ici ani: rrrwrJ �nvi - :ina �• a1 ' 1 = ! � l i > FL � fAtlU ir! • 17 <br /> 8, Designated Facility Name and SiteAddtEss L : R U.S. EPAID Number <br /> trtrei i=.'iet. ;AtiVe T) HI ' C <br /> 1ndimna)ia; 014i Olt , 46241 <br /> Facili one' s • -�c ,. cr : trnn zrse + - - <br /> get 9b. U.S.DOT Description{including Proper Shipping Name, Hazard Class, ID Number, 10. Containers 11 . Total 12. Unit 13, Waste Codes <br /> HM and Packing Group (f any)) No. Type Quantity WUA 1, <br /> W <br /> O 11 jit %IGRA hazard t) .iD ;'Jct ` i: e , Si0t ! u � iii' �1 40.21+ 1 4 <br /> w l I <br /> a 2, <br /> LU - <br /> a Ism <br /> 3. <br /> + <br /> ! <br /> 46 <br /> A,sw <br /> 14, Special Handling Instructions and Additional Information <br /> •! , irt ' �6 ? { � � �� : Reg +.tl ;.ttt? sa 5 +31zu"' a ) <br /> i <br /> 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, <br /> marked and labeledrpiacarded, and are in all respects in proper condition for transport according to appilcable International and national governmental regulations. If export shipment and I am the Primary <br /> Exporter, I certify that the contents of this cons!gnment conform to the terms of the attached EPAAcknowledgmenl of Consent. <br /> I cer61y that the waste rnmimiza8on statement identified in 40 CFR 26227(a) (if I am a large quantity generator) or (b) (it I am a small quantity generator) is true. <br /> Generattor'stOgeroesPrin`te of <br /> ameNdmim gnaure on ay ear <br /> 3-�v �, J ' r .^fv+cJr� Vy 53 <br /> .wj 16, InlematiDnal Shipments <br /> ❑ Import to U.S. 0 Export from U.S. Pod of enlrytexii: <br /> qXFqff Transporter signature fore ods on1 : Dale leaving U,S.: <br /> W 17, Transporter AcknaviedgmeMOfReceipt ofMaterials <br /> Transporter 1 PrintedtTyped Name +gnature J MonthDay ear <br /> z Tra spo er 2 Pdnied/t ams Sign ur Mon ay r <br /> Ott <br /> 1a. isaepency <br /> 18a, Discrepancy Indication Space - ❑ Quaniky 0 Typo 0 Residue ❑ Partial Rejection ❑ Full Rejection <br /> Manifest Reference Number: <br /> oil I <br /> 18b, Alternate Facility (or Generator) U.S. EPA ID Number <br /> <UwU <br /> Fad;t s Phone: <br /> Lou 18c, SignaWre oTAlternate Fadity (or Generator) Month Day Year <br /> a <br /> Z <br /> 19, Hazardous Waste Report Management Method Codes (i.e., codes tot hazardous waste treatment disposal, and regdng systems) <br /> i o t . 2. 3. 4' I <br /> I ! / <br /> T <br /> 0, ign ed FaaTity Owner or Operator: Certificatilin of receipt of hazardous materials covered by the manifest except as tem 1aa <br /> P7tedffypAd Name Signature th Day Year <br /> Signature <br /> t <br /> EPA I'din 8 00-22 ev, 3.051 Previous editions are obsolete. DES1GtJATk : 1 TY ' DES ]NATION STATE (IF REQUIRED) <br />