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'lease print or type.(Form designed for use on elite(12-pitch)pe wr:""ter.) �. Form Approved.OMB No.2050-0039 UNIFORM HAZARDOUS I.Generale i0 Number 2.Page 1 of 1 3.Emergency Response PhoneManifest Tracking Number WASTE MANIFEST CAL 0 0 0 5 .) 7 8 1 8[N 1 36�4778 700805228 tGeneralcrs Name and Mailing Address Generator's Slle Address(e different than mailing address) HCriRTLAf!D 5TEEi_PR, 00JC'T5VVES T,LLC LP 213 KELL%`STREET 242QitiLL55TFEET Lr 'I ftrA.�'5VILLE 4BLt4_t Generators Phone: A1'364'422 5.Transpor!er 1 Company lame U.S.EPA ID Number Eh.VIFe NN NTiAL REO.UVEF`t 51ERVIOE5,VC. r`A.R U 0 Q 1 P 8 2`] 7,Transporter 2 Company Name U.S.ERA ID Number —t 2L—tly,6A Tmyaa611i�tl Ja 5 8.Designated Fa-,Jity Name and Sile Address U.S.EPA 0 Number fU:EC 01-0G'i Fit P'95,12 IA IL E5 510IU-FH BEATT,' il!'y tri rid, Facilih/s Pyne: (7'5;5` 'Lr 44'J 3:.0 U '1 t2`J U 12 ga. 9b.U.S.DOT Description(including Proper Shipping Name:Hazard Class,ID Number, 10.Containers 11.Total 12.Unit HM and Packing Group(f any)) No. Type Quantity Wt./Vol. 13.Waste Codes 1 jl)r:1(t!gCGti HAZAR04tJ t0,'A5 f E,5 0L 10(PA IMT CHIPS} or_, `3 a1 1 70 _ I I1J � Z rL CDi i S I Special Handling Irsfruct ons and Additional Information E 9BI'H59'E-PA!N!CHIP-WAT EF.BASED P,?Ir..T L-H)PE ERG#:9 81. f1/.h " E R 5,;it.Cr. 712:9-4-5A.v BILL T Cr ENV!-Cs5EF « it AR PROPER-PPE 15. GENERATOR'S10FFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are`ully and accurately described above by the proper shipping name,and ere c;assified,packaged, marked and labeledJplaoarded,and are in all respects in proper condition for transport according to appllable international and national governmental regulations.It export shipment and I am the Primary Exporter,I certify that the contents of this consignment conform to the terms of the aCached EPAAcknowledgmsm of Consent. I certify that the waste minlrnizatron statement idenllfied in 40 CFR 262.27(a)(if I am a large quantity general or(b)(f I am a s 9 :ranthy generator)is;rue. Crne fors'Otiercr'sPrinted/Typed Name Sig lure Monfi Day Year �' ✓� t t! Sz-}� `�e<�r�7' � r'� 3 3 1it j 16.International Ship(hants ❑Import to U.S. Excort from U.S. Por,of en i.anspc)der signature(fa exports orfy): Date leaving U.S.: Q� 17.TransporierActmwledgmentofReceipt ofMaterials w Trenspo.ter 1 Prntedirly tl Name Signah re Month Day Year T a. oder 2. -n'd(Typed me gna f,440th Day Year 18.Discrepancy \ �' 18a.Discrepancy Indication Space r r� Quantily �Type 17 Residue LJ PaC:al Rejection ❑Full Reiectlon Manifest Reference Number: 18b.Alternate Facility(or Generator) U.S.EPA ID Number J cc Facility's Phone: L 18c.Signature ofAltercale Facility(or Generator', Month Day Year z Hazardous Waste Report Management Method Codes(i.e.,codes for hazardcus waste treatment,disposal,and recycling systems) 2. 3 4. 3� 20.Designated Facility Gvner or Operator.Cerfificalion of receipt of hzardous materials covered by the manifest except as noted in Item 18a nfedfr red Name9riaturee Month Day )Year �(R-v. 05) Previous eddisKs are obsolete. .�F S'GN,-:%TED FP4 LIT'y'70 'J'SS T HIP-70-IN 7 TATE(f-'F PE-QUIPED)