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Please print or type. (Form designed forum on elite (12 -pit mer) mate Facility for Generator) U.S. EPA ID Number Phone: ., ;- Signature of Alternate Facility (or Generator) Month Day Year In I I I 19. Hazemous Waste Report Management Method Codes (i.e., mtles for hazardous waste treatment, disposal, and recycling systems) 1-017m Approved. OMB No. 2050-0039 UNIFORM HAZARDOUS 7. Generator ID Number 2. Page 1 of 3. Emergency Response Phone 4. M+a"nderr�stt Trach�rg Number WASTE MANIFEST %.j!a,1.�,�+ 4 FLE I5 ,��',J Ge ererors Name and Ma i g Address Ge are ors bee Address (i tl 8eren1 Man mailing address) Generators Phone: imp spother 1 Company Nam U.S. EPA ID Number 7. Transporter 2 Company Name U.S. EPA 11 Number 8. D glaiied Fagliry Name and See Address U.S. EPA ID Number Facility's Phone: 9, 9b. U.S. DOT Description (including Proper Shipping Name, Hazard Class, ID Number, 10. Comainers11. HM and Paddng Group (deny)) Taal Quantity - 12. Unit Wt (vd. 13. Waste Codes No. Type I i. K i 2 2. IM 3. I ) 4. 14. Spatial Handling Instructions and Addlgwal Information 1E. GENERATOR'S/OFFEROR'S CERTIFICATION: Inanity, declare that the contents of this consignment are fully and accurately described above by the proper shipping name, and are classified. packaged, marked and labeled/placarded, and are in all respects in proper condition for transport according to applicable international and national govemmental regulations. a export shipment and I am the Primary Exporter, I cerdty, that Ne contents of this consignment conform to the arms of the attached EPAAcknoxledgmea ofCo isent. I partly that the waste minimization statement identfied in 40 CFR 28217(a) (8I am a large quantity generator) or (b) (8I am a small quantity generator) is true, eneiator me YrintecVTypedNa-Ignamore Month Day ear J F 1S. Imemadonal Shipments ❑ Import to US ❑ Export from U.S. Pon of entry/e irt: Ira Transporter Signature for eXPDrlS only): Date mavlml U.S.: ""--_rorterAcknowledgmem of Receipt of Matenals ,. Transporter 1 Pnnted/Typed Name Signature Month Day year Transporter 2 Printed/Typed Name Stgrature •- o ay ear 118. Discrepancy ..__ 18a. Discrepancy Indication Space ❑ QuarNry, ❑ Type ❑ Residue ❑ Partial Rejection ❑ Full Rejection Manifest Reference Number: mate Facility for Generator) U.S. EPA ID Number Phone: ., ;- Signature of Alternate Facility (or Generator) Month Day Year In I I I 19. Hazemous Waste Report Management Method Codes (i.e., mtles for hazardous waste treatment, disposal, and recycling systems)