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Please print or type. <br />C_ A ----A ll- — — .- <br />.—"/ GENERATOR'S INITIAL COPY <br />UNIFORM HAZARDOUS <br />11 Generator ID Number <br />Z Page I of <br />3. Emergency Response Phone <br />I ­­ W".-- —.1. — 'V Vvz <br />Manifest Tracking Number <br />WASTE MANIFEST <br />1 <br />14. <br />1 <br />JJK <br />5- Generators Name and Mailing Address Generators Site Address (ff different than mating addrem) <br />7 <br />Generators Phone. -I" <br />6. Transporter 1 Company Name U.S. EPA ID Number <br />7. Transporter 2 Goff"" Name U.S. EPA ID Number <br />8. Designated Facility Name and Site Address 1i 4RC- U.S. EPA 0 Number <br />ZA�iT FIC0 Vlj.�-,ST_� <br />Facility's Phone::. - <br />9& <br />9b_ U.S. DOT Description (incluft Proper Shipping Name, Hazard Claw, ID Number. <br />10. Containers <br />11. Total <br />12. Unit <br />HM <br />and Packing Group (I any)) <br />Quantity <br />WLNbI.O <br />13. Waste Codes <br />No. <br />Type <br />cc <br />rY <br />3. <br />4. <br />14. Special Hard ling Instructions and Additional Information <br />'F4*'f?Va0 PPF <br />15. GENERATOR'SlOFFEROR'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 labelleftlacarded, and are in all respect 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 />I cer* that the waste rninimization statement identified in 40 CFR 26227(a) (If I am a large quantity generator) or (b) CC am a small quantity generator) is true. <br />Generatoesiofferoes Nntedrryped Name Signature Month Day Year <br />16. International Shipments <br />F] import to U.S. E❑ Effortfrom U.S, Port Of entrylexit. <br />Transporter signature (1cr exports only): Date Waving U.S.. <br />Ir <br />LU <br />17. Transporter Acknowledgment of Receipt of Materials; <br />I— <br />ix <br />Transporter I PrintedfTyped Name Signature Month Day Year <br />0 <br />IL <br />�zU3, <br />Transporter 2 Pdntedffyped Name Signature Month Day Year <br />I <br />18. Discrepancy <br />18a. Discrepancy Indication Spam Ou.nfity ❑ Type ❑ Residue ❑ Partial Rejection ❑ <br />Full Rejection <br />Manifest Reference Number: <br />18b_ Alternate Facility Generator) <br />(or U.S. EPA ID Number <br />LL <br />Facility's Phone: <br />LLI <br />18c. Signature of Alternate Facility (or Generator)_77k; <br />Month Day Year <br />I.- <br />9 <br />rnC9 <br />19. Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste treatment, disposal, and recycling systems) <br />Uj <br />0 <br />1 <br />- <br />1 2- <br />120. Designated Facility Owner or Operator. Certification of receipt of hazardous materials covered by the manifest except as noted in Item 118a <br />Pmtedffyped Name Signature Month Day Year <br />.—"/ GENERATOR'S INITIAL COPY <br />