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A <br />7cnrm decinnud fnr use nn elite f12-nitchl tvoewrited- <br />so '4© 'SOZZI -4-fo <br />Form Approved. OMB No. 2050-0039 <br />xRM HAZARDOUS y 1. Generator ID Number <br />-z <br />2. Page 1 of <br />3. Emergency Response Phone <br />d, nrfest Tracking Number <br />JJ K <br />STE MANIFEST tae �o 1 554:1 <br />406 -'Zf'a� -•44" <br />012820607 <br />eratoesN eand Mai ling Address Generator's Site Address (if different than mailing address) <br />5 1"I sa C> <br />Roes Phone: 20Q — % % — 62990 <br />sporter 1 Company Name <br />U.S. EPA ID Number <br />:GS <br />1GL1,CU0o3 lo3S Z. <br />sporter 2 Company Name <br />U.S. EPA ID Number <br />�n1�4 LA,620.o1zS Se�o-V7«S <br />mm:t- 039 3Z <br />grated Facility Name and Site Address <br />U.S. EPA ID Number <br />x21 l2iEQ12\�r� '�. SA,..,osc, C71 4Si33 <br />'s Phone: t�-0 - I —O Z <br />G40 bS�j 3(o <br />9b. U.S. DOT Description (including Proper Shipping Name, Hazard Class, ID Number, <br />10. Containers <br />11, Total <br />12. Unit <br />13. Waste Codes <br />No. <br />Type <br />and Packing Group (if any)) <br />Quantity <br />WLNoI. <br />1 X143 -7-7, 4AZAeroo WA-Si6 S9L ibe A4 0. S, <br />is t <br />pmlD° <br />(bed b)9, P611( <br />Z <br />GC <br />28g3. <br />1 P <br />Atej9-eZCilll 94246=5 u-iiE`Soc-IA <br />LVL <br />DSS <br />„ (-&AiNJ , N/A <br />3 <br />C <br />dL3d <br />3.JqA 30-7-7, a6VS �—t.G, 5�0,19.o.5 <br />(��i q PSL <br />� <br />c!j <br />467 <br />4.g <br />30'77, 1tp{yA2DVS whSZE SpLl�rt�,O <br />/81 <br />It i.i <br />t11:010 <br />,N4 <br />J7i� <br />54d� <br />1 <br />�co8 <br />DooU! <br />MSK_ i X26 (.rc2t►D L�Ew Wwl `J <br />Dcw'1 <br />alai H?:InstrucUonsand Addition llnformafion 4, <br />z coy 4®es�� pis s� ar eq <br />l <br />`C> L 4=120ovt SlAa"tS6+1 (2 GAY��'>� ra°16i72 4 r -�cSTE 66.L,u6"i T Gid �* 77 <br />-, rtrE-'gin ca � -t uyQos <br />ENERATOR'SIOFFEROR'S CERTIFICATION: thereby declare that the Fontents of this consignment are fully and accurately described above by the proper shipping name, and are classified, packaged, <br />larked and labeled/placarded, and are in all respects in proper condition for transport according to applicable international and national governmental <br />regulations. If export shipment and I am the Primark <br />xporter, i certify that the contents of this consignment egnfonn to the terns of the allached EPAAcknowledgment of Consent <br />;eNfy that the waste minimization statement idenljfieffin 40 CFR 262.27(a) (if I ant_a large quantity generator) or (b) (if I am a small quantity generator) is hue. <br />doeslOHerofs P'nledlrype, N e ' Signature �--'— —� <br />Month Day Year <br />:rriational Shipments <br />❑ Import to U.S. ❑ Export from U.S. Port of entrylexib <br />- y' <br />rorter signature (for exports only): Dale leaving U.S.: <br />nsporterAckrimledgment of Receipt of Materials <br />prier 1 Printed? ed NameSignature <br />Month Day - Year <br />prier 2 Pr]nXfdrryped Name net <br />Monty Day Year <br />crepancy <br />screpancy Indication Space ❑ Quantity E] Type ❑Residue <br />❑ Partial Rejection ❑Fuil Rejection <br />Manifest Reference Number. <br />temate Facility (or Generator) <br />E' <br />E <br />'s Phone: <br />1! <br />gnature of Alternate Facility(or Generator)Monty <br />DEC <br />Day Year <br />CC 0144 <br />4 <br />u+rdous Waste Report Management Method Codes Q.e., cedes for hazardous waste treatment, disposal, and recycling systems) <br />c• <br />2• 3. <br />NMENTAL HEALrH <br />signaled Facility Owner or Operator: Certification of receipt of hazardous materials covered by the manifest except as nded in Item iSa <br />/Typed Name <br />Previous <br />oigrmrme <br />TO DESTINATION STATE (IF REQUIRED) <br />J <br />16 <br />C <br />11 <br />l <br />( <br />