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tel Please pnnt or Form Approved OMB No 2050-0039 — UNIFORM HAZARDOUS WASTE MANIFEST 1. Generator 10 Number ' it 1._ ,: 2 Page 1 of 3 Emergency Response Phone 4. Manifest Tracking Number 021990765 JJK S Generavs Name and Ma leg Address ' \ Generators Site Address Of different than mailing address) L_ j , ., ,. . ......... \ ' 12_ .._.--) _ Generators Pnone I 6 'ansPorter I Company Name SO EPA ID Number i. . I CH 01.71441.1(13ef.S6 7 Transporter 2 Comnam Name U S EPA ID Number I F Desgnaied Facatty N3rne and S•te Add, s_ • 111, US. EPA ID Number CRI:44400.3.556 Facility's Phone 1 I' gy 30 US DOT Descnbt, I ol,AxIng Proper Shippey Name . azara Class ID Number. 10 Containers 11 Solo' 12 lied 13 Waste Coder HM and Passing Group if any o No T oo, Quanta), WI Vol Ce 0 t— si lY I rtItItt 1 7 C."' 1 1 I. .1 • rt t)11,71, .t, .1 n -1- Llt:.2' t.0 t):111 •. ) __1 ' - - a u..1 z uur 0 4 'a Sowoa Mending Instructions and Addwonai InformabOn TO RE TB/AVED 71.D-3111 APPROVED PPE E P. COMTRasCTOR: BAMOI; ENVIRONMENTAL -;;E:p t.8c Es ,5 GENERATOR'S/OFFERORS CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately descnbed above by the proper shipping name, at are classified. packaged marked and latwiedvararded and are in Al respects in proper ccodibon for transport according to applycable international and national governmental regulatrons It export sr:totem! and Ian, the Pnmary Exporter_ 1 certify that the contents of this consignment conform to the terms of the attached EPA Acknovriedgrnen1 of Consent I cerbfy Mat the waste nrinimizabcn statement /identified in 40 CFR 26227(a) ill( ant a large quantity generator) or (b) (II area small quantity generator) is true Glneratodsorfs pnntollTyped Name Signature / Month Day Year I' --. i L.,...-- I 1 I i l ii al i— 'E Internabonal Shipments IIII Import IOU 5 III Export Porn US i Port of entry/exit. 00 Transporter signature (for ek ports only) Date leaving US . 'TRANSPORTER 17 Transporter Acknoydedgmeni of Recedst of Matenals Transporter 1 PnntedrTyped Name *nature Month Day ,ear, I I / I /1/1 ' 71-1 1.,scorter 2 PrirrtertTyped Name Sqnature , Month Day Yea' 1 1 1 1 15 Discrepancy 1 18a Discrepancy Indication Space NI Quantity IIII Type IN Residue El Partial ReLection Ll Full Rejection Manifest Reference Number. -7i a ,15 c) At Alternate Faddy or Generator) us EPA ID Number Factlity's Phone. I L., I— .kt Z I8c Signature of Alternate Facility Or Generator) Month Day Year I I LI (7, 19 Hazardous Waste Report Management Method Codes P e.. codes for hazardous waste treatment, disposal. and recycling systems. Lu Cs y 2 3 4 20 Designated Facility Owner Or Operator Certliicaboe of receipt of hazardous materials covered by Me manifest except as ncterl in Item 18a I — Pnntedayped Name Signature Month Day Year GENERATOR'S INITIAL COPY