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Please print or type. • GENERATOR I UNIFORM HAZARDOUS
<br />WASTE MANIFEST
<br />1. Generator ID Number
<br />eA(.......0032.0 itti3q
<br />2. Page 1 of
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<br />3. Emergeiggy fte.sp5sgpout...„ .., .,..
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<br />4. Manifest Tracking Number
<br />0 2139 532 7 JJK
<br />Generator's Name and Mailing Address Generator's Site Address (if different than mailing address)
<br />:Ø fivor ops F P.N5., RD. SToc-letot-J/ cA (p/o5 AD tt.u..r.r c.390.170a.48 ,c go 6. .r/)
<br />1_49D+ &LI, #1 /4 C 1 Tz*
<br />Generator's Phone: I
<br />Transporter 1 Company Name ••,t, U.S. EPA ID Number
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<br />7. Tri
<br />sipmorter 2 C mpany Nare U.S. EPA ID Number
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<br />8. Designated Facility' me and Site Address U.S. EPA ID Number
<br />CO 5 6%1 i alea1c,•-'
<br />14io to PC41 itT 'ST Lo Pro/ 0044.,..),,i CA-....., 41,04a 13
<br />Facility's Phone: 6 - -4, 7. -if 3e...- 6 n Aril I CAID6?4 ti090/ 4
<br />ga. 9b. U.S. DOT Description (including Proper Shipping Name, Hazard Class, ID Number, 10. Containers 11. Total 12, Unit Firo and Packing Group (if any)) No. Type Quantity WINol. 13. Waste Codes
<br />1 ' uo.F.3 - ge-f-A Pc442-Alt-Vvis, w tkurc6, Seat-1 C>
<br />C. A rook Pow-1 sr k. 06805 IP att- Soft FAL-TP0"1- if bF ar 1 17,0 p
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<br />1.1,41Vecgt)04 ..5 1.4)11kilf,": / Li 6,1.05
<br />1 O F 1-o "r5 C 1)4 IL FA CilAo-r) at
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<br />14. Special Handling Instructions and Additional Information c27-0-1‘..0/4-ft_cii .-1:-- ,,,
<br />70 0 ZZ. - 00 3 - li Z.Z-1 Pro-c-Li, 0 1,2-ticc,25 • Yvv -1.. te14,q/3 ce 92OLI3
<br />tt-2-7---ov63 .5 0 1,241,2,6.
<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, aid 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 262.27(a) (if I am a large quantity generator) or (b) (ill am a small quantity generator) is true.
<br />Generator's/Offerors Printed/Typed Name Signature % Month Day Year
<br />OP remw, o f 4 6 auir DA-lik 1 40.2 1.0600 1 44e1& I it I (51 2zez- __I
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<br />16. International Shipments III Import to U.S. Lii 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 Signature Month Day Year
<br />IDA Jek% &J.3 4)6 813 I /9/A2-. /1"01C I tl I tr I tatz- Iran r 2 Printed/Typed Name Signature
<br />r)-,_(--_ Month Day Year
<br />I n 12_ i ) FACILITY _ 18. Discrepancy
<br />Discrepancy Indication Space LII Quantity Type Residue Partial Rejection Full Rejection
<br />Manifest Reference Number.
<br />Alternate Facility (or Generator) U.S. EPA ID Number
<br />Facility's Phone: I DESIGNATEI , , Signature of 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. 2. 3. 4.
<br />to. Designated Facility Owner or Operator: Certification of receipt of hazardous materials covered by the manifest except as ncted in Item 18a
<br />
<br />)rinted/Typed Name Signature Month Day Year
<br />
<br />___ ,,,,,,, ,-„, ,,, - .-- . .... • • - W3 1)I
<br />- . - eaitions are o so e e. SIGNATED FACILITY TO EPA's e-MANIFEST SYSTEM
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