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Please print of type.(Form designed for use on elite(12-pitch)typewriller.) Form Approved.OMB No.2050-0039 <br /> UNIFORM HAZARDOUS 1 1.Generator ID Number 2,Page t of 3 Emergency Response Phone 4.Manifest Tracking Number <br /> WASTE MANIFESTt. GBF <br /> ri Generators Name and Mailing Address Generators SileAddress(f different than mailing address) <br /> Gqnerator`si)1rw8:' <br /> 6 Transporter 1 Canpany fVame U.S EPA ID Number <br /> 7 Transporter 2 Company Name US EPA 10 Number <br /> 8 Designated Facility Name and Site Address U.S.EPA ID Number <br /> ,JeW F,�XIJlv�.tAQ*4 LL4. <br /> 14-000 Rack R45a.11. <br /> FacAily'sPhone: kaWdt <br /> 9a. 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Qaosa,ID Number, 10 Containers 11 Total 12.Unit <br /> HM and packing Group(if any)) No. Type Quantity Wt.A/6. 13.Waste Codes <br /> 1. <br /> 2 <br /> 0 <br /> 3. <br /> 4 <br /> 14 Special Handling Instructions and Additional Information <br /> 1,441ALI'.1; llv3 aC AA 1641illlelr)AND'Alf—AaK PPE, <br /> ::+w j ".orf'T�' 'Pro ili"?I <br /> 15. GENERATOR'SIOFFEROR'S CERTIFICAPOW I hereby declare that the contents of this consignment are fully and accurately described above by the proper shipping name,and are dassified,packaged, <br /> marked and labelecl(pacarded,and are in all respects in proper condition for transport according to applicable onterratioral 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 r <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 generator}is true. <br /> C-OmWsIOffercrs Pnnied/Typed Name Signature Month Day Year <br /> 16-Wernational Shipments Import to U.S. L71 Export from U.S. Port or entrylexit: <br /> Transporter sigirroolure(for exports only): Dale leaving U.S <br /> 17 Transporter Acknoveledgrynt of Receipt of Mallenals <br /> w <br /> Transpofter 1 Printedrry*Name SiJHatur Month Day Year <br /> 0 <br /> Trans Wer 2 PfinteidWlTyped ame Signature Morin Day Year <br /> oC <br /> 18.Discrepancy <br /> 8a.Discrepancy Indication Space Otortily Residue <br /> L D Type E:Partial Rejection C Full Rejection <br /> Manifest Reference Number: <br /> 111b.Alternate Facility(or Generator) U S.EPA ID Number <br /> Faic[lity's Phone: <br /> U, 48C.S",%reofAlternate FarAity(or Generator) Muntr Day Year <br /> !R <br /> 19.FdtaiW"Waste RbWo Management Method Codes(i.e.,codes for hazardous waste treatment.disposal,and recyding systems) <br /> 7 3. 4. <br /> 20.Designated Facilitypwneror or Operator:Certification of receipt of hazardous materials covered by me manifest except as noted to}tern I Ba <br /> Printed/Typed game Sgnalure Month Day Year <br /> FRA Form 8tJR&v.3-05) Previous editions are obsolete. <br /> GENERATOR'S INITIAL COPY <br />