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Please print or bLaL Form designed for use on eine (12 -pitch) typewriter l <br />crm rurrn or uu-cc lKev: 3-051 Previous ealpons are obsolete. 1-11 <br />TRANSPORTER'S COPY <br />- <br />UNIFORM HAZARDOUS <br />WASTE MANIFEST <br />- - <br />1. Generator ID Number <br />!^ <br />L 60 �` i 7 � � <br />2. Page 1 of <br />,;; <br />3. Emergency Response Phone. 4. <br />,. rvnn nyprvvev. VMC NO, ZUDU-03H <br />Manifest Trackln Number <br />i� .3 <br />� <br />%' /f <br />002500117 G B F <br />5. Generator's Name and MailingAddress - Generator's Site Address (if different than mailing address) <br />,OIL 1�'t�� <br />Generator's Phone.' <br />6. Transporter 1 Company Name U.S. EPA ID Number <br />7. Transporter 2 Company Name U.S. EPA ID Number <br />8. Designated Facility Name and Site Address / U.S. EPA ID Number <br />Facility's Phone: 6 <br />ga, <br />9b. U.S. DOT Description (including Proper Shipping Name, Hazard Class, ID Number, <br />10. Containers <br />11. Total <br />12. Unit <br />HM <br />and Packing Group (if any)) <br />Quantity <br />WLNoI. <br />13. Waste Codes <br />No. <br />Type <br />o <br />( K{111 �.i�.;1�''C +� jr�-,��,4 <br />7 <br />#•F, <br />�I` <br />W <br />c� <br />_ <br />... <br />3. <br />4. <br />14. Special Handling Instructions and Additional Information <br />15. GENERATOR'S[OFFEROR'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, <br />packaged, <br />marked and labeled/placarded, and are in all respects in proper condition for transport according to applicable international and national governmental regulations. 9 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 />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 genera!M is We. <br />Generator's[ is Nntedrryped Name SiXn tore M th Day Year <br />F -S ( I <br />J <br />i- <br />16. International Shipments <br />❑ Import to U.S. ❑ Export S. Port of 'ntrylexil <br />Transporter signature (for exports only): 1.7 Date . aving U.S.: f <br />w <br />17. Transporter Acknowledgment of Receipt of Materials <br />N <br />Transporter 1 PnntedlTyped Name Signalurni ` Month Day Year <br />SIL. <br />Q <br />Transporter 2 Printed/Typed ame Signature Month Day Year <br />t- <br />18. Discrepancy <br />18a. Discrepancy Indication SpaceEl ❑ Partial Rejection <br />Quantity ❑Type El Residue I El Full Rejection <br />Manifest Reference Number. <br />181b. Alternate Facility (w Generator) U.S. EPA ID Number <br />J <br />U <br />LL <br />� <br />Facility. Phone: S <br />w <br />18c. Signature ofAOemate Facility (or Generator) Month Day Year <br />Q <br />Z <br />19. Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste treatment, disposal, and recycling systems) <br />1. <br />2. - <br />3. <br />4. <br />20. Designatell Facility Owner or Operator. Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a <br />Printed/Typed Name SSignature Month Day <br />/ <br />/Year <br />crm rurrn or uu-cc lKev: 3-051 Previous ealpons are obsolete. 1-11 <br />TRANSPORTER'S COPY <br />