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Rliase pont or type. Farm deal ned for use on elite[12-pitch) Bwritar.) Form Approved.OMB No,2050-0039
<br /> UNIFORM HAZARDOUS 1'Generator ID Number2.Pege 1 oU3EmergencyRew nse Phone 4.Mgnitest Tracking Number
<br /> WASTE:MANIFEST "f KS
<br /> 5,Generators Name and Mailing Address Generarofs Site Address(ifdi$erent Mar mailing address)
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<br /> GenaratoesPhone, d✓ "''�'k �` �'`fe
<br /> B.TfaR7t�rrfCQ7Pqy ei[,�'f ,$"rs y, �.:. U.$.EPA iDNumber
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<br /> 7.Transporter 2 Company Name US EPA ID Number
<br /> s.f7esignatedFacility Name and SileAddress U-S.EPA IDNumhe(
<br /> 6060
<br /> FaCifil eS Phone:
<br /> 9a 9b,U,$,DOT Description[,rduding Proper Shipping Name,Hazard Gass,10 Number, 10,containers t1.Tatal 12,Unit
<br /> HM and Packing Group[d any)) No. Type 00antity WLA(pl. 13.WasteQde;
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<br /> 14.Special Handling losWtGonsand Additional lnlormation
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<br /> ib. G£NERATORWOPFEROR'S CERTIFICATION: I hereby declare that the wnlents of'this 6onsignmentare fully and accuralaly described above by the proper shipping name,and are dasaiW,packaged,
<br /> marked and Iabelerilplacarded,end are in all respects in proper condition for transpon'according to applicable intemaWnaiand national governmental regulations,If export shipment and I am the Primary
<br /> Exporter,I certify that the content;of this ocnsignmsnt conform to the terms of the allactied EPAAoknovAedgmenl of Consent
<br /> certify that the waste minimization statement ideal Aed in 40 CFR 262.27{a)(if I am a large quantity generator)or(b)(if I am a small quantityOjlf(fAtor)is true.
<br /> Ganeraior'slofteroeN PMNdlTyp�{e++sd Name z Signal r o ' �r ,�'.: Month Day Year
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<br /> 16.Irrfematlonal Shipments
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<br /> rt 10 U.S. ❑Fxpdrt from U.S. Port df entrylexit:
<br /> a Transporter signalure(for export onty): Dale leaving U.S.;
<br /> UM 17.Tranvolter Acknowledgment of Rowipt of Malef ala
<br /> 1Tansporter•1'Ppote&TypedName Signature -- Month pay Year
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<br /> Transporter2PdnlediTypedName �'$t�r,�ture "' �R,y Month Day Year
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<br /> 16.DiscrrpanCy
<br /> 183.Discrepancy Indication Space quantity Type j ❑Full Rejection
<br /> ❑T ❑Residue ©Partial Rejection
<br /> Manifesl Relerence Number:
<br /> IBb,Altornale Facility(or GL neralor) U.S.EPAID Number
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<br /> L6 Faciiity"3 Phone:
<br /> W 1aC,Signature of Alternate Facility(or Generator) Month Day Year
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<br /> 2 19.Hazardous Waste Repoft Management Method Godes(i.o.,codes for hazardous waste bealment,disposal,and recycling systems)
<br /> LU t. V 2. 3, 4.
<br /> 20.Designated Facility Owner or Opecalou Certification of receipt of hazardous matariafs covered by the manilc,at excepJvs nclsd in Item I8a
<br /> Prated Typed Nameor*^ :7 Signahrfe ""r a f Month Day Year
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