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Please pent or type.(Form designed for use on elite(12-pitch)typewrite4)F;1 77 ?-0t?i - q Form Approved.OMB No.2050-0039 <br /> UNIFORM HAZARDOUS I Generator ID Number 2 Page 1 0l 3.Eme gency Response Phone 4.Man Tracking Number <br /> WASTE MANIFEST _ 011848919 F L E <br /> 5 Generator's Name and MailixJA (rfiffrfiliirent than mailing address) <br /> Motuttarr. H-:+r,r `Nares: Tr��r;-Wont�tar;t <br /> 1+:lld�i(o cn Rn�r en►aK <br /> .Transporter 1 C aMeir U.S.EPA 0 Number <br /> 7.Transporter 2 Company Name U S EPA ID Number <br /> X&D ,eoo-t- :;r-n-C `D 03A '7S't%tT C_o wtbZP(asX3rj'7y <br /> 8.Designated Facility Name and Site Address U.S.EPA 10 Number <br /> ipar.Ha borsGrassv Mountain Let_: <br /> I All c t= 7 M;I N , +t ,F K .M1ll_ c i � 7 � 1 �t� 1 i •r c� <br /> �►1e. JT�:4n25 <br /> ga, 9b.U.S.DOT Descnp o r_1 r i ng Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit <br /> 13.Waste Codes <br /> HM and Pacllng Group if any)) No. Type Quarf y Wt/Vol <br /> 1 <br /> X NOWWRA HAZARDOUS WASTE,LIQUIDS.(OFSEL,WATERT TP +__ __.--- ;-- <br /> 3. <br /> I j <br /> 4 <br /> ( <br /> 14.Special Handling Instructions and Additional Information <br /> 7� <br /> 1 r'Ti�n.567R5 � X 1 � I CS <br /> ;K 76M <br /> R faON�'fWrbtiy Aeda're Kat tfieoari leih VV ilIV.Atl T&A* paged: <br /> marked and labeled/placarded,and are in all respects in proper condition for transport according to applicable inlemational and national govemmental regulations.If export shipment and I am Ute Primary <br /> Exporter,I certify that the contents of Uris consignment conform to the terms of the attached EPAAcknowledgment of Consent. <br /> I certify that the waste minimization statement identfied in 40 CFR 262.27(a)(if I am a large quantity generator)or(b)(if I am a small quantity generator)is true. <br /> enerato s! ro s Printed ypV Nam L440 R- Signature on ay ear <br /> rt, A/ AU v � S GU° <br /> _j 16.IntemationaShipments <br /> F__ ❑Import to U.S Export from U.S. Port of entrylexiC - <br /> Z <br /> Transporter snature for exports onl . Date leaving U.S.: <br /> X 17.Transporter Acknowledgment of Receipt of Materials <br /> LU <br /> T porter 1 P nledfi a Name gnaMe n Y Year <br /> {�rC�L Z� 110 <br /> I <br /> QZ Transporter <br /> s� <br /> 2 Pnntedv� ped NameMonthay ear <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space Quantity TY" ❑Residue ❑Partial Rejection ❑Full Rejection <br /> Manifest Reference Number <br /> 18o Alternate Fadity(or Generator) U.S.EPA ID Number <br /> J <br /> U <br /> LL <br /> Facillitys Phone: <br /> w 18c.Signature of Altemate Facility(or Generator) Month Day Year <br /> a <br /> Z <br /> N19.Hazardous Waste Report Management Method Codes(i.e..codes for hazardous waste treatment,disposal,and recycling systems) <br /> C 1 2. 9. 4. <br /> H.)�� <br /> 20.Designated acilly Owner Operator Certification of receipt of hazardous materials covered by the mandest except as in Item 18a <br /> S' at WREQUIED)WA <br /> EPA 8700 ev.3 05) Prevous editions are obsolete. IGNATED FACILITY TO DESTINATION STATE(IF <br /> {o:rs:a prAn.0 �,+:rf•:o pr.n�-lr ,lip narmitc fnr Anil will arrPnt the 4:1 o5fs 0-15 yPn Prat rlr is chinning <br />