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case print or type. <br /> UNIFORM HAZARDOUS 1.Generator ID Number Form Approved.OMB No.2050-0039 <br /> WASTE MANIFEST �"��� 2.Page 1 of 3.Emergency Response Phone 4.Manifest Tracking Number <br /> 5.Generator's Name and Mailing Address 31 507 8+ 1 - 1025963491 JJ K <br /> Aft Moftift Generator's Me Address(if different than mailing address) <br /> •,�: � �� TifmtMd <br /> S2b3 <br /> Generator's Phone: <br /> 6.Transporter 1 Company Name <br /> U.S.EPA ID Number <br /> f tt r ti`1N � CA84041 8 Q 79 7 <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> B.Designated Facility Name and Site Address U.S.EPA ID Number <br /> &Lh <br /> *rr�yy oFp4��p%4% rVV■0 s n� r <br /> Facility's Phone: •9 K• <br /> 9a. 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit 13,Waste Codes <br /> HM and Packing Group(if any)) No Type Quantity Wt.Nol. <br /> O 7 1. �LM 9". � �1l,9et4,(amu ! <br /> w <br /> Z 2. <br /> w <br />�a <br /> 3. <br /> 4. <br /> 14.Special Handling Instructions and Additional Information <br /> 1) WR:022746 ptan6C#101669 JR CbnftAdor CiHD <br /> WOW VprqpfM PIV MA ffng,SVAI*n 3�-WE'b th °ems <br /> 15. GE <br /> CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by the proper shipping name,and are classified,packa <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 Prime <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)(if I am a sm II quantity generator)is true. <br /> Generator's/Offerors Printed/Typed Name Signature Month Day <br /> 1;�'k 6""'C�L <br /> J 16,International Shipments <br />_ ❑Import to U.S. ❑Export from U.S. Port of entrylexit: <br /> Transporter signature(for exports only): Date leaving U.S.: <br /> C 17.Transporter Acknowledgment of Receipt of Materials <br /> Tra>a4r 1 Printed/Typed Name Signature Month C <br /> Transp rter 2 Printed/Typed Name Signature" Month <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space <br /> ❑ Quantity ❑Type ❑Residue ❑Partial Rejection FI <br /> 18b.Alternate Facility(or Generator) Manifest Reference Number: <br /> U.S.EPA ID Number <br /> 3cility'S Phone: <br /> Ic,Signature of Alternate Facility(or Generator) <br /> Month <br /> Hazardous Waste Report Management Method Codes(I.e,,codes for hazardous waste treatmpnf dicnnool a <br />