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Please print or type. UNIFORM HAZARDOUS 1 Generator ID Number Form Approved.OMB No.2050-0039 WASTE MANIFEST 2.Page 1 of 3.Emergency Response Phone 4.Manifest Tracking Number Generators Name and ill ^r JtJ K gAddressrt cur' f i L'. f it Ex,r !�;�• Generator's Site Address(if different than mailing address) 7125 Ccnt:!,•1ni;:l Phar, _ .r.,,l;trl:.a, T14 37209r t,'.97. ereratorsPhone: 151`•3 � . Thorn'.oil F^c, .Transporter l Company Name Lo,i1, C,95; 42 U.S EPAIDNumber Transporter 2 Company Name U.S.EPA ID Number 8.Designated Facility Name and Sile Address U.S.EPA ID Number 1 .t. - Lori t .,,.h C '?0 '1 Facility's Phone: (3 JL 2 14151 9a. 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, r n t'1 i 1�;1!(,}`;1;r t HM and Packing Group(d any)) 10 Containers 11_Total 12.Unit No. Type Quantity WtNol. 13.Waste Codes o �l,(9�zctduaa V1,2:..� Sclid(01c;:d. G,arla) :r 7 ul CntT�r"tiblo U. 4111d, n.c) i 4 Spepal Handling Instructions and Additional Information I. �..11G 171 l;9811 �.r_r+^ l 912�,St� 4�:.•�. 1 ..- cc's - � 1•:B- C na:1d:?oar,a:�n:%,:cue. ._. n•t - 15. GENERATOR'SIOFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by the proper shipping name,and are classified,packaged, marked and tabeled/placarded,and are in all respects in proper condition for transport according to applicable intemab( aland national governmental regulations.If export shipment and I am the Primary Exporter,I certify that the contents of this consignment conform to the terms of the attached EPA Acknowledgment of Consent. 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 small quantity generator)is true. Generator'slOflerorzPnnted(Typed Name`s Signatyre 1 Month Day Year _j 16.International Shipments ►— ❑Import to U.S. ❑Export from U.S. Port of entry/exit: ? Transporter signature(for exports only): Date leaving U.S.: W 17.Transporter Acknowledgment of Receipt of Materials LLJ Transporter 1 Printed/Typed Name Signature aMonth Day Year Transporter 2Printed/Typed Name Signature Month Day Year t~ 18.Discrepancy 18a.Discrepancy Indication Space puantity ❑ Type ❑Residue ❑Partial Rejection ❑Full Rejection Manifest Reference Number 18b.Alternate Facility(or Generator) U.S.EPA ID Number J _ U L, Facility's Phone: W 18c.Signature of Alternate Facility(or Generator) Month Day Year Q Fp,nmted[Typed ste Report Management Method Codes Q.e.,codes for hazardous waste treatrnenl,disposal,and recycling systems) 2'ility Owner or Operator.Certification of receipt of hazardous materials covered by the manifest except as nt7ed in Item 18a e Signature Month Day Year PA Form 870 - ev.12-17) Previous editions are obsolete. GENERATOR'S INITIAL COPY