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Please print or type.(Fenn desi ned for use on elite(Q-pitth)typewriter.) Form Approved.OMD No.2050.0039 <br /> UNIFORM HAZARDOUS 1"enelatec'""ibef 2,Page i of 3.Emergency Response Phone 4.Manlfesl Traekhiumber <br /> WASTE MANIFEST t;A I �_�� .; :trt�r t t��, 1010897635 JJK <br /> 6. f Ias>Gen_rl eraioi's Name and MaitngAddress Generators SileAddress(if different than maiing address) <br /> UB ^; <br /> iil- r, <br /> 19`:fy,1 '- 130±I !'s1r11'I '33' <br /> t9fr Irl-i.:ii - v,_ MAN ..i'1 J _ ., <br /> Generators Phone: 2101", '] -•'.It <br /> 8.Transpater 1 Company Name U.S.EPAID Number <br /> 7.Transporter 2 Company Nance U.S.EPA 10 Number <br /> 8.Oas!gnated Facility Name and Site Address U.S.EPA ID Number <br /> AY <br /> CA A t 0 0 <br /> FacA s Phone: <br /> 9a, 9b.U.S.DOT DescdpWn Cmdudng Proper Sh!ppng Name,Hazard Class,ID Number, t0.Conta`ners ii.Total MUM 13.Waste Codes <br /> HM and Paving Group(if any)) No. Type ouantity SYtNol. <br /> t_ t O r t' l ! } <br /> 3� _. <br /> w 2' <br /> nprEDVE—D <br /> 3. <br /> JUL 2 7 2017 <br /> ENVIRONMENTAL H ALTH <br /> td.Special Hand-Ing InstrucCons and AM onal InfeMiall6q <br /> }.1,',`�r , i`:; �. .. . rift (,:-G NCt E '..tiCt.:....rd:t.: 1t1• ti?t�+.� ' #i)i�iiiist: !ca. (:: ti!)- <br /> i rIECTIVE _�� S l`:it.f1Y60'Z- <br /> 15. <br /> 15. GENERATOR'S(OFFEROR'S CERTIFICATION:I hereby declare that the contents of thts cons!gnment are fusty and acwatey described above by the proper sW-.ng name,and are dassAed,pactagc-tl, <br /> marked and labetedlPecarded,and are In a'.i respects an proper condition for transport accotdag toappkab%Inlemational and natonal governmental tegALio ts.It export sixpmenl and 1 am the Pr-mart' <br /> Exporter,I certify that the oontents of this consignment conform to the terns of the attached EPAAcknaMedgment of Consent. <br /> I Certify that thewaste d(ft4ation statement Identified In 40 CFR 281.27(x)pi I am a large quantitygenetata)of(b)(11 ama"quantity generator Is true. <br /> Generators) et sPrintedlTy Name tura Month Day Year <br /> 11 <br /> Gr = <br /> 1 .tntema' al Shipments <br /> F 11 Import to U.S. ❑Export from U.S, Pal of entry exit <br /> z Transporter d9nature(for exports only): Data leaving U.S,: <br /> U= V.TrartsporterAckwWkdgmenlofRece'plofMaterials <br /> UW <br /> cn <br /> Transpoder ed+FypedName Sgnahue EtoMh Day Year <br /> ( <br /> Aanspater 2 PtintedlfYped Nante S!'gnature Month Day Year <br /> t- <br /> 18.Discrepancy �� <br /> 18a.Discrepancy Ird-calion Space ElCuanBy O TYPe El Re11st6ue t_l Partial Rgktiw ❑FO Re^- 6.. <br /> Manifest Reference Number: <br /> 18b.Atternaie FaORy(of Generator) U.S.EPA ID Number <br /> J <br /> rJ <br /> ur FacAty's Phone: <br /> Qo 18c.S�MureofNternatoFadhity(orGene(akx) Month Day Year <br /> z <br /> 19.Hazardous Waste Report Management Method Codes(L9.,codes for hazardous waste treatment,disposal,and recydrg systems) <br /> coo 1. 2, 3. 4, <br /> ` 1 <br /> l <br /> 20.Des.*aledFaci'ity OAner or Cperata;CeAi6cation o!recrptof hazardous materials covered bytho mandest except rtcted 1n flem l8a <br /> Prnce Hama S:rnaturo ! ` / Month Day Year <br /> -- "�- <br /> EPA Form 87C •22(Rev.3.05) Prehousediffmare obsolele. DESIGNATED FACILIT TO DESTINATION STATE (IF REQUIRED) <br />