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rl'r i'se pnn!,-or type. (Form designed for use on elite (I typewriter.) <br />UNIFORM HAZARDOUS 1. Generator ID Number <br />WASTE MANIFEST � r" y �' f) () () ft e <br />4 <br />F- <br />L <br />II Foram Iyp0a Name <br />.qjn,tuiro <br />'jil atuo Wier si t" waste the jelletater VS filopmac <br />GENERATOR'S INITIAL COPY <br />2. Page 1 of <br />3. Emergency Response Phone <br />4. Man as me nt <br />If tT ki 1 Number <br />it'i <br />0001123934 MWI <br />5. Generators Name and i M in Address <br />Mailing Gerember's Site Address if different than mailing address) <br />114iVo <br />Generators Phone: 9C., IA -1 AT f IN fy-Vti�. fr� t <br />6. Transporter 1 Company Name U.S. EPA ID Number <br />M A t? 0 '-,' 9 'A Vt 9 7 IS 0 <br />7. Transporter 2 Company Name U.S. EPA ID Number <br />8. Designated Facility Name and Site Address U.S. EPA ID Number <br />�4- all "arbompolletarm"llow LR: <br />10A00 wilest Loke"I Roilid A 1 It �� 14 0 Q 7 5 21 if G <br />['411triftwiltow t' -A'13206 <br />Fadlh �s Phone: ili61,1 <br />ge. <br />9b. U.S. DOT Description (including Proper Shipping Name, Hazard Clan, ID Number, <br />10. Containers <br />11. Total <br />12. Unit <br />13. Waste Cod es <br />No. <br />Type <br />HM <br />and padding Group lif any)) <br />Quantity <br />Quantity <br />1 W)MV " M -NA IIA-'ir-16 efil5i W*;% 1XIMM, flAlf X <br />V`Uil <br />343 <br />0 <br />z <br />2 <br />3 <br />4. <br />14, Special Handling Inhictions and Additional Information <br />1 3. TG1s56']i4 - <br />15, 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 labeled/placarded, and are in all respects in proper condition for transport according to applicable international and material governmental regulations. H export shipment and I am the Primary <br />Exporter, I carfirlythat the contents of this consignment conform to the terms of the attached EPAAcknowledgment of Consent <br />I certify that the waste minimization statement identified in 40 CFR 262.27(a) (if I am a large quantity generator) or (b) (If I am a small quanifty, generator) is true. <br />Generatoes/0fferarj5 Pjjntecirryped Name Signature Month Day Year <br />16. International Shipments <br />Elimporitou.s. ElExport from U.S. Pod of entry/exit: <br />Transporter signature (for experts only): Date leaving U.S.: <br />17 Transporter Acknowledgment of Receiptof Materials <br />Transporter I PdritedrTyped Name Signature Month Day Year <br />0 <br />Transporter 2 PrintedfTyped Name Signature Month Day Year <br />Discrepancy <br />I18. <br />18a. Discrepancy Indication Spam D Quantity EITYP, EIResidue D Prettru Rejection El Full Rejection <br />Manifest Reference Number. <br />18b. Alternate Facility (or Generator) U.S. EPA ID Number <br />LL FacilVs Phone: <br />18c. Signature of Alternate Facility (or Generator) <br />Month Day Year <br />11; Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste treatment, disposal, and recycling systems) <br />0210*, <br />2. <br />4. <br />Designated Facility Owner or Operator: Certification of receipt of hazardous materials covered by the manifest except as noted in Item 1 Be <br />II Foram Iyp0a Name <br />.qjn,tuiro <br />'jil atuo Wier si t" waste the jelletater VS filopmac <br />GENERATOR'S INITIAL COPY <br />