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Please print Or type. Form Aorsroved. 0MB No. 2050- GENERATOR ). I UNIFORM HAZARDOUS
<br />WASTE MANIFEST
<br />1. Generator ID Number
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<br />2. Page 1 of 3. Emergency Response Phone
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<br />4. Manifest Tracking Number
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<br />Generator's Wine and Mailing Address Generator's Site Address (if different than mailing address)
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<br />Generator's Phone: C() t 1 - 11 1 2 - 74 I
<br />Transporter 1 Company Name U.S. EPA ID Number
<br />1 /i i i \ 1 ,', - t I »vii L:,11) 1011 (ti Trworter 2 Company
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<br />Name U.S. EPA ID Number
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<br />Deti Nagnated Facility Na e and Site Address U.S. EPA ID Ntinber
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<br />I 1.1-11)02..,,i11/)e10/% Facility's Phone: '",i.2 I i;,2 - r rl i I 5 -
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<br />g, 9b. U.S. DOT Description (including Proper Shipping Name, Hazard Class, ID Number, 10. Containers 11. Total 12. Unit Hrvi and Packing Group (if any)) No. Type Quantity WI Not 13. Waste Codes
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<br />Special Handling Instructions and Additional Information
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<br />601 tf, ±, /001.s 7
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<br />GENERATOR'S/OFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately descnbed above by the proper shipping name, artl are dassified, packaged,
<br />marked and labeled/placarded, and are in all respects in proper condition for transport according to applicable intemationaland 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 gelerator) or (b) (ill am a small quantity generator) is true.
<br />.• ........... Gerierator's/Offeror's Printed/Typed Name ..... ,..... Signature Month Day Year
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<br />International Shipments ...I .. c. f,
<br />Import to U.S. Export from U.S. Port of entry/exit:
<br />Transporter signature (for exports only): Date leaving U.S.:
<br />Transporter Acknowledgment of Receipt of Materials TRANSPORT Transporter 1 Printed/Typed Name Signature Month Day Year
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<br />Transporter 2 Printed/Typed Name ;
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<br />Signature Month Day • Yea"'
<br />- (.1 C li".X./ I 2. I I) 1 ) FACILITY 18. Discrepancy
<br />Discrepancy Indication Space 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 DESIGNATE( Signature of Alternate Facility (or Generator) Month Day Year
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<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 />20. Designated Facility Owner or Operator: Certification of receipt of hazardous materials covered by the manifest except as nded in Item 18a
<br />Printed/Typed Name Signature Month Day Year
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<br />orm -(Hey. -Previous editions are obsolete. TRANSPORTER COPY
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