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t <br />Please orint or tvne- fFn,�n dasinnarl fnr nca nn aloin r��_, +rht rvno. m. <br />Fnnn Ann--ei OKAR KI n ')nr:n-noon <br />-- t,.v.. v-vvr , icrivuo aumw a arc uuavrcrc. Vq II K v 1 r... _ DESIGNATED FACILITY TO GENERATOR <br />UNIFORM HAZARDOUS <br />1. Generator ID Number <br />2. Page 1 of <br />3. Emergency fiespoase Phoria 4. <br />Manifest Tracking Number <br />WASTE MANIFEST= <br />DAT <br />5. Generators Name and Mailing Address Generator's Site Address (if different than mailing address) <br />.. .._. .. .. i3.... ,. _ <br />Generators 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 Faa7ty, Name and Site Address U.S. EPA ID Number <br />FaaWs Phone: <br />9& <br />9b. U.S. DOT Description (including Pmper Shipping Name, Hazard Class, ID Number, <br />10. Conlainers <br />11. Total <br />12. Unit <br />HM <br />and Packing Group (f any)) <br />Quantity <br />Wt-fvol. <br />13. Waste Codes <br />No. <br />Type <br />1. <br />W <br />Z <br />2. <br />�-i �tJ✓ <br />-------- <br />3. 3. <br />4. <br />14. Special Hand§ng Instructions and Additional In6omua8m <br />15. GENERATOR'SIOFFEROR'S CERTIFICATION: I hieWdeclare that the contents of this consignment are fully and accurately described above by the proper shipping name, and are classed, packaged, <br />marked and labeledlplacarded, and are in all respects in proper condition for transport according to applicable international 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. <br />certify that the waste minimization statement identified in 40 CFR 262.27(a) (it I am a large quantity generator) or (b) (if l am a small quantity generator) is true. <br />Generators/Offerors Printed/Typed Name Signalur@ r Month pay Year <br />—r <br />1— <br />16. Intemational Shipments <br />❑ Import to U.S. ❑ Export from U.S. Part <br />Z <br />ofd _ <br />Transporter signature (for exports only): ode karig U.S: <br />w <br />17. Transporter Acknowledgment of Receipt of Materfals <br />li— <br />Transporter I Prin"edayped Name Signature 1 MoOth Day Year <br />M <br />Transporter 2 PrinfedlTyped Name Signature Month Day Year <br />18. Discrepancy <br />laa. Discrepancy Indication Space Quantity ❑T ❑ <br />Type-Resld4le-,. 'A 1�,Rariatlwcfiort ❑Full Rejection <br />r7 <br />t -Mai ft�fel�itderiuir i 1Ci:�? permits(s) <br />16b.Alternate Facility (or Generator) } ur, and Will CC:CeP I <br />J <br />this gettarator is shipping. <br />LL <br />Facility's Phone: <br />W <br />18c. Signature at Alternate Facility (or Generator) Month Day Year <br />a <br />Z <br />19. Hazardous Waste Report Management Method Codes (.e., codes for hazardous walle Ireabrietd, disposal, and recycfirg systems) <br />1. e <br />2 <br />S. <br />4. <br />i <br />`{, j <br />- <br />20. Designated Facility Owner or Operator. Certification of receipt of hazardous materials WYared by the manifest except as noted in Item 1 @a <br />Printecirryped Name Signature Month Day Year <br />-- t,.v.. v-vvr , icrivuo aumw a arc uuavrcrc. Vq II K v 1 r... _ DESIGNATED FACILITY TO GENERATOR <br />