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Please print or type. Form des ed for use on elite(12 itch) peoter) F::rm Approved.OMB No.2050.0039 <br /> UNIFORM HAZARDOUS 1.Generator ID Number L �j 2.Palin I of 3.Emergency Response Phone 4.MerlUest Tracking Number <br /> WASTE MANIFEST C.AL-D QL3 a �, �" 1 1 800 r ati—9300 017617001 JJ K <br /> 5 Generators Name and Mailing Addressf�{„`_ e-e i_ GeneratDrs dile Address(it dif`:eren!man ma soli ald-ets) <br /> /S�fs3 7•{to^40'V Roq,) f <br /> '14C"� f7 <br /> Generator's Phone <br /> fi Transporter 1 Company Name US EPA ID Numbar <br /> i P a r <br /> 7 Transporter 2 Company Name S EPA ID Number <br /> 8 Designated Facility <br /> yN�Name and Site Address 1 <br /> 1 K 1)I n L)S EPA IDN * <br /> 7 n (l1 Lj/r0-tl I.vJQrw <br /> Facili s Phon _ CAT0900 2-4-6,, <br /> 9a, 9b.U.S. OT Description(including Proper Shipping Name,Hazard Crass lD Numb.,r 10 G�ntainers it Tota 12 Unit <br /> HM and Packing Group(d any)) No Type Quantity WtNoi 13 Waste Code <br /> 1 A;Or,/ N.-qi, fr. <br /> 0 ri! '';� Ot`� V TT y}y rOC� aC <br /> z 2. V l�� <br /> 3. <br /> 4 <br /> i <br /> I 14 Spyrial HanAnInatntrlkinj anA MAitk}nBl lnlnrmal nn <br /> VAtw-a (AA r welct-C <br /> i---z CrIg irac <br /> 15. GENERATOR'9f0 FEROR'S CERTIFICATION: I hereby d&are that the contents of this consignment are fully and accurately described above by the proper shipping name,aril 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,11 export shipment and t 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 /> I certify that the waste minknization statement identified in 40 CFR 252.27(a)(If I am a targe quantlty generator)or 41Lam a small rdi nerator)is true. <br /> LCanerator's/Offeror's PrtntedlTyped Namp Signature if I Month Day Year <br /> 1X I /.. , Il . I n `� k / i I0 • IJ21Itr01 <br /> V VYf s Q <br /> 1 .Intemalwnel h nts El <br /> Import to U.S ❑Export from U.S. Porto UylexiC <br /> Transporter signature(far exports only): la leaving U.S.: <br /> 17 Transporte(Adrcwiedgment,54RecxiptofMalefials <br /> aTra e 1 Prinhedlryped a Sig IV Month Day Year <br /> O <br /> a <br /> z Transporter Pnra yped Name Signature Month Day Year <br /> 1 1 1 1 <br /> I a.'Discrepancy <br /> 18a Discrepancy Indication Space ❑ Quant T Quantity ❑Type ❑Residue Partial Rejection ElFull Rejection <br /> ' Manifest Reference Number: <br /> 18b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> a <br /> v <br /> sal Facifitys Phone <br /> 18c.Sio_nature of ANemate Facility_(Or Generators Month Day Year <br /> 1�1 1 t r 1 <br /> Z <br /> N19.Hazardous Waste Report Management Method Codes(i.e,codes for hazardous waste treatment,disposal,and recd ON systems) <br /> a 1. 91 2 4. <br /> 3.VZ <br /> 20.Designated Facility Owner or Operator Certification of receipt of hazardous materials covered by the manifest except as noted In Item 18a <br /> PrintedR ame r S re Month Day Year <br /> C 'Mada <br /> Oalha <br /> EPA corm a'rnn_.)n lot., ':nr% o.,.,,,cus cd;lftns 7;1 r r <br /> (-- <br /> EPA "" ' '""""" " "' ULWNAI EU FACILfTY TO DESTINATION 5-FATE(IF HhUUIHEU) <br />