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Please print or type, <br /> UNIFORM HAZARDOUS 1.Generator ID <br /> WASTE MANIFEST _ Number Form Aopruved.OMB No 2050-0039 <br /> 5.Generator's ti' ! n���^' 2.Page I of 3.Emergency Response Phone 4.Manifest Tracking Number <br /> Name and Mailing Address O 9 9 2 869 E LE_' <br /> i�' r r\^ F '• - Generator's Site Address(if different than mailing address) <br /> AT <br /> 1C r+ ^�' q�'•;^ Lie.i1Ffli T9 <br /> Generator's Phone:9r 0 =s[ - - Vot OF N <br /> e.Transporter 1 Com ar' <br /> �` y Name <br /> ^ U.S.EPA ID Number i <br /> 7i Transporte_r 2 Company,game <br /> U.S.EPA ID Number <br /> 8.Designated Facility Name and gito Address <br /> - U.S.EPA ID Number <br /> Re <br /> Facility's Phone: <br /> 9a, 9b.U.S.DOT D�es�criptjon(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers HM and Packing Gany)) 11.Total 12 Unit 13.Waste Codes <br /> No. Type Quanrily NJtNot, <br /> 1 a <br /> Z tart <br /> fR�E tt ialir) t !c!. Sli�lll <br /> Z 2. <br /> LU , <br /> t7 <br /> 3. <br /> 4. ! <br /> 14.Special Handling Instructions and Additional Information r1`C,1+ <br /> SA r F.uA Ste,- ,�.�s one 3 <br /> 15. GENERATOR'SIOFFE R'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by the proper shipping name,arcs are classified,packaged, <br /> marked and labeledlplacarded,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 /> certify that the waste minimization statement identified in 40 CFR 262.27(a)(if I am a large quantity generator)or(b)(11 am a small quantity generator)is true. <br /> Generalcies/Offerci Printed/Typed Name Signature Month Day Year <br /> 16,International Shipman s Import to y pod from U.S. Port of entrylexit 7 <br /> F- Date leaving U.S.: <br /> ? Transporter signature(for exports only): <br /> tY 17.Transporter Acknowledgment of Receipt of Materials Month � Do Year <br /> LLITransporter) t r9e Signature / <br /> �/ro Month Day Year <br /> a Signature <br /> ez Transporter-2 Printed/Typed ame LT I AL <br /> E•- <br /> 18.t.iiscrep cy <br /> ❑ �TYfo El Residue ❑Partial Rejection ❑Full Rejection <br /> 18a.Discrepancy Indication Space Quantity <br /> Manifest Reference Number. <br /> U.S.EPA ID Number <br /> 18b.Alternate Facility(or Generator) <br /> J <br /> U <br /> uu.. Facility's Phone: Month Day Year <br /> W 18c.Signature of Alternate Facility(or Generator) <br /> Q <br /> Z ement Methlxi Codes(i.e.,codes for hazardous waste treatment disposal,and recycling systems) <br /> N19.Hazardous Waste Repor1t Manag 2 g <br /> w t oil <br /> d Faclllry owner or Operator:Certification of receipt of hazardous materials covered by the ms 9fe`ue�st cept as noted in Item 18a Month Da(y� Year <br /> 90.Designate <br /> PrintaUTyped Name <br /> EPA Form 87 <br /> 0 (Rev.12-17) Previo s editions are obsolete. DESIGNATED F CILITY TO EPA's e-MANIFEST SYSTEM <br />