|
Form Approved. OMB NO. 2050-0039 Please print Of t GENERATOR ) I UNIFORM HAZARDOUS
<br />WASTE MANIFEST
<br />1. Generator ID Number
<br />(--• It C.- 0 C. --3 1 ,k \... R..-z_vi
<br />2. Page 1 of
<br />1
<br />3. Emergency Response Phone
<br />%viz, 1.2,4 • 1 ( r-s L.
<br />4. Manifest Tracking Number
<br />0 1 9 7 0 4 4 9 5 JJK
<br />S Generator'S Name and Mailing Address Generates Site Address (if different than mailing address)
<br />1-- f ot-cv eitizi (..,H.-1-. 1 - ..,,,,, E. . v---ri-t W.
<br />k.,0,,,, s..1.--pi 4r. s, kv•P
<br />v-tc_vi•A>,...i s:, , 4 Ar -1-3 7_7_4 1 1.n --,.-54--k-t c-v-i , c--4- 1 s- -z--- 1
<br />Generators Phone: - I
<br />S. Transporterl Company Name U.S. EPA ID Number
<br />-1.1"--C-Nr--1fr -C .1.•••/ V 1/4 C1- IV 1-/VCf,.1 -SvA.. 3'el7,...\> V (...er j C-A-11) .',-..3
<br />-7. Ira " ortfi teeir,;,,ompany Name , U.S.IPA ID Number
<br />s: 0 V (A(.4.1)n, Ll/vc 1 CA 6agff-100 let_
<br />8. Designated FaciW tile and Sile Address U.S. EPA ID Number
<br />CV„,0 •%15 ,-1 4. 6-\Ylatc...Nr:
<br />t1-111 1 --..
<br />. \J k.,1=.',/ ‘,.. VZVA. f-A4 , CA_ 1=i SI. \ ....5
<br />Facility's Phone:
<br />ga, 9b. U.S. DOT Description (ncluding Proper Shipping Name, Hazard Class, ID Number, 10. Containers 11. Total 12. Unit 13. Waste Codes
<br />HM and Packing Group (if any)) No. Type Quantity WE No.
<br />... ... .. , 4-6-P e> oZiN
<br />.... a 70 . - • • "4:. . • iiit,
<br />2' -4. % c_- kA. ii cm. ,---,i-i-v-i-t v4 ‘. '.. . KA LA 0-.•-•-lQi. /
<br />N40S, (ekk Y 1 acckcite), 14. I 1)601_ IMM
<br />.r. , 1...
<br />CO. -55 1-•
<br />
<br />,
<br />
<br />14. Special Handling Instructions and Additional Information
<br />-Pi A_t),ke.,?. t c--A, \SP--
<br />)-• i i -1 33
<br />IS. GENERATORIS/OFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are fufly 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 apricable IntematonN and national governmental regulaaons. If export shipment and lam the Primary
<br />Exporter, I cedily that the contents of this oonsIgnment conform to Pie terms of the attached EPA Acknowledgment of Consent.
<br />I certify that the waste minimization statement Identified in 40 CFR 262.27(a) (if lam a large quantity generator) or (b) (if I em a small quantity generator) Is true. .
<br />Generator's/Olferoes Printed/Typed Name Signature
<br />'TV - V-412 tt-c__4" li:-. l-z-i..-- ..S .--‘ t /1-1,i, I
<br />Month Day Year
<br />I. .....
<br />_1
<br />F--
<br />is. International Shipments Export from U.S, Port .f en • ' Import to U.S. .
<br />Transporter signature (for exports only): D.& leaving U.S.: -RANSPORTER 17. Transporter AcknOwledgment of Receipt of Materials
<br />Transporter 1 Prinledffyped Name Signature Month Day Year
<br />l i t I 7 H A .-cv4, I
<br />Printed/Typed Name Month Day Year
<br />Trans Signature
<br />
<br />I 11 I to Ii-t DESIGNATED FACILITY ji 18. Discrepancy _
<br />OIscrepancy Indication Space QuantIty CI Type II
<br />Manifest
<br />Residue 111 Partial Reiection 111
<br />Reference Number:
<br />Full Rejection
<br />Alternate Facility (or Generator) U.S. EPA ID Number
<br />Facitilys Phone: I
<br />t8. Signature of Alternate Facility (or Generator) Month Day Year
<br />1 I
<br />19. Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste treatment, disposal, and recycling systems)
<br />1. 2.
<br />0 ) 11 )
<br />4.
<br />20. Designated Facility Owner or @rater:Certification of receipt of hazardous materials covered by the manifest except as noted I 8a
<br />Printed/Ty Name Signe Month Day Year
<br />/7 I 2 j
<br />-...... ......-... - . ..... ......., -,-,.... rr, ao_ _ se a niirnn, t•VOTC1.1
<br />EPA F (Rev. 12-17) Previous editions are obs ete. I.MbIbNAItU I-M.11_11Y tu trms e•rvimNircoi oloi rvr
|