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Form Approved. OMB No. 2050-0039
<br />riease plIlll VI typo.
<br />UNIFORM HAZARDOUS
<br />WASTE MANIFEST
<br />1. Generator ID Number
<br />C_Ac2... C(3012 15;-406;
<br />2 Page 1 f
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<br />3. Emergency Response Phone
<br />CI °(' -CC.' °le 9 .°
<br />4. Manifest Tracking Number
<br />022228735 JJK
<br />Generator's Name and Mailing Address
<br />,..N .:i:•- 1 0 l'-1
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<br />ce6KAQ4 V tt--1-(5-71 M't ?..'79`oct ,:•-riSG -l'i (7,,
<br />Generator's Site Address (if different than mailing address)
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<br />1-04-rt--1 p___.p i CA ri,s--4 _
<br />Transporter 1 Company Name U.S. EPA ID Number
<br />e\ A-9-4c4 k='• I 0.-ev. 6'1 $0-7:1"--7 e, to B
<br />-14- f-Je,t7 IL-I
<br />Transyort212/Comgar2pme/ c., • atay:isprt.) U.S. EPA ID Number
<br />4. ,.• c
<br />esignated Facility Name and Site Address ... EPA ID Number
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<br />Facility's hone: - -!->. IP 2.-- Li .1 - -Cl/ g E.- I nkteap 43, t>9 01(A
<br />ga. 9b. U.S. DOT Description (including Proper Shipping Name, Hazard Class, If) Number, 10. Containers 11. Total 12. Unit 13. Waste Codes
<br />HM and Packing Group (if airy)) No. Type Quantity Wt.Nol.
<br />1* NA0r, F l'T fv-z...i,a, c2.-Tsl'...>-... 'l..)-.),:s"T-E- 50 l- I, ''(- ..,- -C-P-4\. Z•Sr..._ cc
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<br />4.
<br />14. Special Handling Instructions and Additional Infornaktion ,..._
<br />VC-- 1 `.3 Q't, 1-k' I C-A-x: -,3-D -CO- 4.)---roe- F-e-." , i...1
<br />30F, A.*___ 4-CO . \ . 147 .•*--":42._ 2-• ,c1 cie?
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<br />15. NERATOR'S/OFFEROR'S CER
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<br />FICATION: Hier y
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<br />declare that the contents of this consignment ore fully and accurately described above by the proper shipping name, art 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 ani Itie 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 lam a large quantity generator) or (b) (ill am a small quantity generator) Is true,
<br />Name cr›,J T LA"'Fui _i Signatu...!---- Month Day Year
<br />v. %bit:. Generators/Offerors Printedffyped .,-..--:`,4‘.4
<br />I 7- i 9-3-
<br />_, 16. International Shipments LII Export from U.S Port of entrylexlt:
<br />_
<br />Import to U.S.
<br />spoiler signature (for exports only): Date leaving U.S.: Tran • '
<br />W 17. Transporter Acknowledgment of Receipt of Materials
<br />Ii2
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<br />
<br />Tra , porter 1 Printed/Typed Name Signature Month Day Year
<br />14 )
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<br />isport Pri d/Typ d me Signetl Month (Thy Year 017 Aa
<br />. 4/zesfy 1 ----1-7/....„... / (.5 1,t2,W7 I 4--- DESIGNATED FACILITY --3' h 18. repancy J
<br />r I-J Quantity Li Type Residue Partial Rejectico ri Full Releclion Discrepancy Indication Space i
<br />Manifest Reference Number:
<br />Alternate Facility (or Generator) U.S. EPA ID Number
<br />Facility's Phone: I
<br />Signature of Alternate Facility (or Generator)
<br />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.
<br />) H ) )4
<br />2. 3. 4.
<br />20. Designated Facility Owner or rator: Certification at receipt of hazardous materials covered by the manifest except as nded in Item 18a
<br />Printed/Typed Name Signatue. Month Day Year
<br />„,.......-----------,--__
<br />4 1 c P M .9....e....5nresnesai A rm.% e API! ITV Tfl CDA/c el - A IA A hilP ig2S.PRYI. S ITNI
<br />EPA Form 8790-2 Rev. 12-17) Previous editions are obsolete.
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