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I<, F3Hllr* -13-0589977 I��IIIII�I�����IIIIIII�'I� <br /> Please print or type. 0 0 7 2 7 5 B 7 4 3 K S <br /> Form Approved.OMB No.2050-0039 <br /> UNIFORM HAZARDOUS 1.Generator ID Number _ a y�_ v r- <br /> 2.Pe 3. i P, r 0.ManNestTackiNumber <br /> WASTE MANIFEST 007r2'756 <br /> 79 SKS <br /> 5.Generator's Name and Mailing Address Generator's Site Atltlress(if different than mailing address) <br /> Generators Phone: P!`49._;-. <br /> 6.Tran,", 4 ,-,�, ?I•p,- U.S.EPA ID Number TYfr �h•4.r_TA <br /> S TNN 1. <br /> 7.Transporter 2 Company Name U.S.EPA IO Number <br /> 8.Designated Facility Name and Site Address r' cANI H F'Fgnr?^ SAIN c`c U.S.EPA ID Number <br /> ., n'+ REP R E9" Prlrl T <br /> Facility's Phone: <br /> ga 91.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Una <br /> HM and Packing Group(if any)) No. Type Quantity Wtwt/Vol. 13.Waste Codes <br /> � <br /> 1 1l ttlri rJa nC <br /> SSMh1FB�l + F r Tnq r ' <br /> Ft _ e. <br /> ?$LENES, TAFN r r <br /> W <br /> FOO DOOI <br /> 3. <br /> t <br /> 4. <br /> i <br /> 14.Special Handling instructions and Additional Information <br /> 3 <br /> N> a y + -1 b ._:.. kT'; �s � t .`: +;a r -- � r IJ✓'3 <br /> 15, GENERATOR SIOFFEROR S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately descrbed above by the proper shipping name,and are classified,packaged, <br /> marked and Iabeledlplacarded,and are in all respects in proper condition for transport according to applicable intemabonal and national governmental regulations.R export shipment and I am the Primary <br /> Exporter,I certify that the contents of this consignment conform to the tens of the attached EPAAcknoMedgment ofC t. + <br /> 1 certify that the waste minimization statement identified in 40 CFR 262.27(a)(if I am a large quantity genemlor)or(b 1 am a small quantity erator)is true. <br /> erors Printed/Typed Name Signature Month Day Year <br /> 9AM 2 z w <br /> 16.International Shipments 1 <br /> F ❑ImpoNo U.S. ❑Export from K. ort ofentryledt: <br /> ? Transporter signature(for exports only): Date leaving U.S.: i <br /> W17.TmnsporterAcknowledgment of Receipt of Materials <br /> ' T - Pdntedlfyped Name ignature Month Day Year <br /> ° 2 J <br /> Q der nntedlfype erne Signature - Month Day Year <br /> -t Z ZL <br /> } B.Discrepancy <br /> 18a.Discrepancy Indication SpaEl ce <br /> Quantity El Type ❑ ElElResidue Partial Rejection FUII Rejection <br /> Manifest Reference Number: x <br /> 18b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> J <br /> U <br /> LL Facility's Phone: <br /> W 18c.Signature of Alternate Facility(or Generator) Month Day Year <br /> Q <br /> z <br /> S2 19.Hazardous Waste Report Management Method Codes(i.e.,codes for haimmous waste treatment,disposal,and recycling systems) <br /> 2. 3. 4 <br /> 1 20.Designated Facility Ovmer or Operator.Certification of receipt of hazardous materials covered by the manifest except in Item 1 <br /> PdntedlTyped Name Signature Month Day Year <br /> A-A 12 <br /> EP4Foup970p2 (RQv 121zj Pevio DESIGNATE,RfAUlL1Vw17Ele-MANIPESTSYSTEM <br />