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Please print or type. (Form designed for use on elite f 12-oilchl tvnmerifarl <br />! <br />UNIFORM HAZARDOUS 1. Generator ID Number <br />2. Pae 1 of <br />Page <br />3.6ne ryenry Response Phane <br />rmm nbPnvvea. unto rvo. [wu-W3S <br />4. Manifes[Trncking Number <br />! <br />WASTE MANIFEST <br />�/ <br />J <br />S. Generators lors Name and MailingAdtlress - _ Generators SmAddress (it amemnl than mining address) <br />I <br />Generator's Phone. <br />I <br />6. Transporter 1 Company Name U.S. EPA ID Number <br />1) <br />i 7. Transporter 2 Company Name <br />U.S. EPA ID Number <br />�B. <br />r Designated Facility Name and Site Address <br />I U.S EPA ID Number <br />Facilitys Phone: _ <br />gz <br />Sb.U.S. DOT Description Proper Shipping Name, Hazard Class, ID Number, <br />10. Ccnlainers <br />77. Total <br />12. Unit <br />HM <br />and Peeling Group (if ani <br />Quantity <br />wuvcl.Ce <br />13. Waste Codes <br />No. <br />Type <br />0 <br />2 <br />CD <br />3. <br />4. <br />j <br />14. Specal Handling Instructions andAdiitidal Information - <br />118. <br />GENERATORSIOFFEROR'SCERTIFICATION: I hereby declare Nat the writersa'Ills mnsignmenl are fuly, and accurately described above by the pmpershipping name, and are classified, packaged <br />1 I <br />marked and labeled!placarded, and are In all respects in Proper condition for transport according to appficahte international and national govemmenlal regulate". If export shipmentarid l am the Primary <br />Exporter, I tardy that the confenis of this consignment conform to the terms of the attached EPAArknowledgment of Consent. <br />I ratty that the waste minhnizatian statement identified in 40 CFR 26Z27(a) (f I an a large quantity generator) or (b) (dl am a small quantity generator) is I ue. <br />Generalor's(OHemrs Primed/Typed Name almahae Month Day Year <br />nil <br />F— <br />16. Intent Shipments <br />❑ import Wus. ❑E)podfmm U.S. Portoexit <br />� <br />Transporter signature (for exports only): Date leaving U.S: <br />17. TrarsporterAcknwAedgment of Receipt of Materials <br />o' <br />Transporter l PdntedRyped Name Signature M4nN Day Year <br />d <br />r <br />Q l <br />Transporter 2 Prinledrfyped Name Signature Month Da Year <br />Y <br />s <br />A <br />18. Discrepancy <br />lila. <br />Discrepancy Indication Space ❑ Quantity❑Type ❑ Residue ❑Partial Reied]. ❑Fu8 Re)esti n <br />Manifest Reference Number. <br />1 <br />Be. Altemale Facility (of Genertor) U.S. EPA IO Number <br />J <br />U <br />ra— Fadntys <br />Phone: <br />C3 18% <br />Signature oWlemale Facility(or Generator) f.1enN Day Year <br />d <br />19. <br />Hazardous Waste Report Management Method Codes (.e., codes for hazardous waste treatment, disposal, and recycling systems) <br />to <br />G 1. <br />2 3. 4. <br />p20. Designated Faalitywn <br />Omer or Operator. CeNfiratian of receipt of hazardous materials covered by the manifest exceptas noted mm Ite18a <br />11 Prmlewlyped Name Signature Mordh Day ear <br />1 <br />:DA G..... sine a 0.... a <br />DESIGNATED FACILITY'S COPY <br />