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-Plo— nTinfnrtvna (Pnrrnri4-,innp.dfnruse nnplitpfla)%T)PvdritAr) <br />Form Armiroved- OMB No. 2050-DO39 <br />UNIFORM HAZARDOUS <br />11. Generator 1p NgTber,. <br />2. Page 1 of <br />3- Emergency Response Phone <br />4. Manifest Tracking Number <br />0 0 2— <br />0 79 <br />' <br />JJK <br />WASTE MANIFEST <br />S. Generators Name and Mailing Addresss, Generators Site Address (if different than mailing address) <br />I <br />Generator's on a: <br />6. Transporter 1 Company Name <br />U.S. EPA ID Number <br />a <br />7. Transporter 2 Company Name <br />U.S. EPA ID Number <br />8. Designated Facility Name and Site Address <br />U.S. EPA ID Number <br />Oil <br />^ P, W <br />Facility's Phone: i <br />COP -P, E., G; �S 14 1 <br />9a, <br />9b. U.S. DOT Description (including Proper Shipping Name, Hazard Class, ID Number, <br />10. Containers <br />11. Total <br />12. Unit <br />HM <br />and Packing Group (if any)) <br />Quanttty <br />WL/Vol. <br />13. Waste <br />Codes <br />No. <br />Type <br />uJ <br />2. <br />LLJ <br />3. <br />4. <br />4. Special Handling instructions and Additional -information <br />5. 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 labelQdlplacarded, 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 EPAAcknowledgment of Consent. <br />I certify that the waste minimisation statement identified in 40 CFR 262.27(a) (if I am a large quantity generator) or (b) (if I am a small quantity generator) is true. <br />GeneratorslOfferoes Printed/Typed Name Signature <br />Month <br />Day.Year,'!. <br />J <br />16. Internatil onal Shipments <br />1:1 Import to U.S. D Export from U.S. Port of entrytexit: <br />Transporter signature (for exports only): Date leaving U.S.: <br />UJ <br />17. Transporter Acknowledgment of Receipt of Materials <br />Transporter) PrintedfTyped Name Signature <br />Month <br />Day Year <br />Z <br />Transporter2 PrintedlTyped Name Signature <br />Month <br />Day Year <br />18. Discrepancy <br />111a. Discrepancy Inclicafion Space El Quantity El Type ❑ Residue <br />El Partial Rejection ❑ <br />Full Rejection <br />Manifest Reference Number: <br />18b. Alternate Facility (or Generator) <br />U.S. EPA ID Number <br />Facility's Phone: <br />Uj <br />18c. Signature of Alternate Facility (or Generator) <br />Month <br />Day Year <br />19.Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste treatment, disposal, and recycling systems) <br />. 1 <br />1 2. —F—_ <br />1 4. <br />20. Designated Facility Owner or Operator:: CertffibaCon of receipt of hazardous materials covered by the manifest except as noted in Item 18a <br />Printed/Typed Name Signature <br />Month <br />Day Year <br />EPA Form 57UU-U (Kev. J-ub) Previous editions are obsolete. <br />GENERATOR'S INITIAL COPY <br />