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.daSe print or type. (Form designed for use 0111 e1rB (12-DitChl tvicewriter.) "�l fl". DESIGNATfiff FkCfLITYTO GENERATOR UNIFORM HAZARDOUS 1. Generalorb —Number 2. page I of 3. Emergency Response Phone 4. •... ......... -' i ..... .....•......,,, M a n I I a a I Tra c k 1; i —�,Tb WASTE MANIFEST n)' 21 /103 11966 009479260 J J K 5, Generator's Name and mailing Address Generators Site Address (if different than mailing address) 2 �2OD 77,j !'000 Generalizes Phone: 6. Transporter I Company Name 11. - U.S. EPA ID Number U3 C2',1)003963592 7. Transporter 2 Company Name U.S. EPA ID Number B. Designated Facility Name and site Addis P—LBA C4 HMj60Pt3, U.S. EPAID Number ''51 suor) c -AD 159 q q Facifil es Phone: 9a, 9b. U.S. DOT Description(including Proper Shipping Name, Hazard Class, ID Number, 10, Containers 11. Total 12. Unit HM and Packing Group (if any)) — No Type Ourmlity WL Nol. 13, Waste Codes ""w'P3 JA'Af-) I of 9 JA 2. 3. 4. DEC 1201 ------- 14. Special Handling Instructions and Additional Information J ER 'l 7'1 15. GENERATOR'SIOFFEROR'S CERTIFICATION: I hereby declare that the contents of (his consignment are fully and accurately described above by the proper shipping name, and are classified, packaged, marked and laboledliplacanded, 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 Expoiter, I certify that the contents of this consignment conlonin to the tons of the attached EFAAcknowledgment of Consent. I cerlifoat the waste minimization statement identified In 40 CFR 262.27(a) if I am a large quantity generator) or (II) (if I am a small quantity generator) Is [me, Gonerator'slOffefol"s /Ifinted/Typed Name Signature Month Day Year /z —1 16. International Shipments 11 Import to U.S. ❑Exiprl from U.S. Pon of entrylincil: Transporter signature (for exports only): Date leaving U.S.: 17. TranspoiderAcknowledgment of Receipt of Materials 0 Q, Transporter I PrintediTyped ame — Signature Day Year TZ.:5se- GicWc-�Q5 zvj t -1112 Z Transporter 2 Printoor typed Name Signalu Month Day Year 18. Discrepancy' 18a. Discrepancy Indication Space ❑Ourinfity ❑Type El Residue ❑ Partial Rejection ❑Full Rejection Manifest Reference Number., 18b. Alternate Facility (or Generator) U.S. EPA ID Number sa Facillys Phone: 18c. Signature ofAltemao Facility (or Generator) Monty ay Year Z 0 M19. 1 Hazardous Waste Repoli Management Method Codes (.e., codes for hazardous waste treatment, disposal, and recycling systems) 2, 3. 4. 120. Designated Facility Omer or Operator: Cerlificatiorn of receipt of hazardous materials covered by the manifest except as noted In Item I Be Printedfryped, Name Signature Year A/ CnA r. DESIGNATfiff FkCfLITYTO GENERATOR