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Pleat,,R print or type.(FofTmn dLlsi sed fir use on elite(12-pitch i Form Approved,OMB No.2050-0039 <br /> 1 mber <br /> UNIFORM HAZARDOUS I.GeneralorlDNureber ?.PagLIa 3. Response Phone 4,1 Tracking Nu <br /> WASTE 1 0 0 0 8 SKS <br /> $.Generators Name and Mailing Address GBnerator's Site Address(if different than mairir g address) <br /> r�Z 'i 0 1 t 7 3 A R L P <br /> Generator's Phone: <br /> 6.Trangp4rter I company eine U.S.EPA ID Number <br /> T X, J"0"NX <br /> 7.Transporter 2 company Name U.S.EPA ID Number <br /> 8.Desi li Facility I and Site Address SU'TFM1S-- VIC U.S EPA ID Number <br /> 9 <br /> CA ql4Iq2i'i <br /> racili Phone: <br /> ga. 9b.U.S.DOT Dasvipi;on(including Proper Shipping Name,Hazard Class,10 Number, 10.Containers 11.Tdal 12.Unit 13.Waste Codes <br /> Him and Packing Group faany)) No, Type Quantity "01. <br /> is 1Lj g-1 S i >Ft A,T 1"1" ?1 A,(6 f,;I AL 2, LN 1 6 3 <br /> Flu I'll <br /> LLJ <br /> 4 <br /> I&Spe6al Handing kirtnuelli and Aftional Information <br /> .7 C—'M379� f <br /> 15. GENERATOR'SlOFFEROK$CERTIFICATION: I I dedoro that the contents o1 Uric consignment are fully and accurately described above by the I shipping name,ard we classIfied,packaged, <br /> marked and labeled/placarded,and are in all ieui in proper ottridillon fir Iranspod a=rding to applicable International and national governmental regulations.if shipment and I am be Primary <br /> Exporter,I ceriffy III the contests of this oonslgriment conform III ii terms of the attached EPAAcknoWodgment of Consent <br /> I care fify that the waste minImbitation statement identified in 40 GFR 262.27(a)(if I a large quantity generator)of Cdl am a arroll quantity geneiatpr)"' true. <br /> —— . . , ,9 <br /> Gearator's/Oftror's Printai Name. Signature Day Year <br /> 16,Intemallionat Shipments <br /> . E]Import to U.S. Export from II Port of entr'yldxit, <br /> Transporter signature(for exports only): III leaving U.S.: <br /> ffi 17.TwsporWAdT*M9gmRn1 of Receipt of Materials <br /> Trans"r 1 Printed/Typed Nam j S nate i f Month Day Year <br /> (X9 <br /> -X Transporter 2 Pfiriftaryppe Name Month Day Year <br /> 18.Discrepancy <br /> 18a.Ciactai Indication Space Ll Q..nlity ElType El Residue Padial Rejection Fuli Rejection <br /> I Reference Number, <br /> 18b.Alternate FacAly(of Generator) U S.I ID Number <br /> cs <br /> Faci$t�s Rhone: <br /> iny- <br /> 18c.Signature of Akernata Facility(or Generator) Day ear <br /> 19 Hazardous Waste Report Management Method Codes I codes for hazardous waste trealment,disposal,and recydii sysiberns) <br /> 2. 3. 4. <br /> 20.Designated Facilt Oyme or Operator:Certification of receipt of hazardous materials covered by the manifest except as noted in Item 181, <br /> Printed ype(lName e, I Day Year <br /> "T <br /> 899-3 TWOZOd 06Z—.L 916D798S9Z6uaaj�{—�a� 01 ,—BT—IZ <br />