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Please print or type. (Form designed for use on elite (12-Dit n'ter.l <br />"�'00....GENERATOR'S INITIAL COPY <br />rune ryrpiuvuu. vmo No. Luou-wee <br />UNIFORM HAZARDOUS 1 1. Generator ID Number 2. Page 1 of 3. Emergency Response Phone , 4. ManNaat Treeking Number <br />WASTE MANIFEST - �' <br />,_ , s F ' w1 'JJK <br />11�r <br />5. Generator's Name and Mailing Address Generators Site Address (it ar terent than mailing address) <br />Generators Phone: e- <br />6. Transporter 1 Company Name 'a U.S. EPAID Number <br />--,,,r,rV lijinit. <br />7. Transporter 2 Company Name - U.B. EPA ID Number <br />Y <br />B. Designated Facllity Name antl Site Address U.S. EPA ID Number <br />.-%4>i-✓„rwAll tl Afhtl"f8ata:ia431.3. <br />Aft 7:10:18. <br />Facility's Phone: PIES <br />ga <br />91a. U.S. DOT Description (including Proper Shipping Name, Hazanl Class, 10 Number <br />10. Containers <br />11. Total <br />12. Unit <br />HM <br />and Packing Group (if any)) <br />QuantityWt./Vol. <br />13. Waste Codes <br />No. <br />Type <br />smaire ,.ax 7. i,ryas i.ds n n.s <br />W <br />W <br />2' fI. naaarublai, <br />(7 <br />.•wr-<•.•:+i i..vta 1 :.1, napncity), 7.1.., Imil f54? <br />3. <br />4. <br />14. Special Handling Instructions and Addifional Information <br />.%..19:YgJ ?) I-00il Oz1:)�137 <br />[: Wirt?, ^•.PHI,'in; QroST ds :SIx10, AP LCi•TO it Ii[:•x i^ ..'• <br />f)E fi - S�c0.hx11 `T♦ 8C. b. tPC FPrJi]6�6 vc till. riT4 p.fF£ NRYc'1%i1gY-;. <br />r.;. ixr*r rr:>T)y','",:. !12"73Hzy <• <br />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, <br />marked and labeledlplacarded, and are in all respects in proper condition for transport according to applicable intemabonaland 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 EPAAcknowledgmenl of Consent. <br />I mildly that the waste minimization statement identified in 40 CFR 21 (If I am a large quantity generator) or (b) (XI am a small quantity generator) is true. <br />Generat6rslOfierers PrintedfTyped Name Signature Month Day Year <br />16. International Shipments ❑ <br />Import to U.S. ❑ Export from U.S. Pod <br />_ <br />of enby/edt <br />Transporter signature (for exports only): Date leaving U.S.: <br />W <br />17. Transporter Acknowledgment of Receipt of Materials <br />OTransporter <br />1 PrintedRyped Name Signature - Month Day Year <br />CL <br />Go <br />ii <br />z <br />Transporter 2 P intedi-Typed Name Signature 9 Month Day Year <br />r— <br />18. Discrepancy <br />I <br />18a. Discrepancy Indication Space ❑ Quantity, ❑ Type ❑ Residue ❑ Partial Rejection ❑ Full Rejection <br />Manifest Reference Number: <br />Ab. Alternate Facility (or Generator)U.S. <br />EPA ID Number <br />J <br />V <br />LL. <br />Facility's Phone: <br />W <br />18c. Signature ofAltemate Facility(or Generator) Month Day Year <br />a <br />z <br />N19. <br />Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste treatment disposal, and recycling systems) <br />p <br />1. <br />2. <br />20. Designated Facility Owner or Operator: Certification of receipt of hazndous materials covered bylhe manifest except as noted in Item Ise <br />Pdnted)Typed Name Signature Month Day Year <br />FPA <br />o— 119nn_ ip— 3 051 P.... d..... ,.aa...... .... ..�.� <br />"�'00....GENERATOR'S INITIAL COPY <br />