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0 <br />PlFlase mint nr Wine IFnrm dnsinnad W rile nn oma fII- ae61 <br />��, �.1„�.. ev�f �,alivma evmmie ria ouealero. DESIGNATED FACILITY TO GENERATOR <br />1. Generals ID Number V�„� ry�P� V vau. vmU .1u. <voolvoa <br />UNIFORM HAZARDOUS 2. Page 1 of 3. Emergenq Response Phone 4. ManifirstTrackigNumb@r <br />WASTE MANIFEST <br />T 10060065996 FLE <br />_ <br />S. Generator's Name and Mailing dress Generators 1eAdres225 <br />s A' than mailing address) <br />CenitaD Valley WMte <br />VW, W, Ttxrtmr F�ckelcl <br />�E <br />IGenrer4ror <br />s Phon'e0 <br />027 <br />6ran <br />. sporter 7 y p <br />U.S. EPA ID Number <br />Adencad Chdnicel Tratispw kvc, (SV) i;AR00DU'?f 540 <br />7 Transporter 2 Company Name U.S. EPA ID Number <br />8 Designated Facility Name and Site Address U.S. EPA ID Number <br />kill str„�A (wrIlak. IteaDltert <br />3Edith El4ud "L: Nia;0CUi,!A)8,,Q7 <br />face i Phone�lJ X7107 <br />ri�'vi <br />y'�s <br />ga. <br />9b U.S. DOT Description troubling Proper Shipping Name. Hazard pass, ID Number, <br />10. Containers <br />tl.Totai <br />12. Unit <br />HM <br />and Packing Group (it any)) <br />Quantity <br />Wt.Nal. <br />13. Waste Codes <br />No, <br />Type <br />0 <br />. h''tRCRA KaWdWds 3!"'1888 Staid , 01y SDliddat <br />J7 <br />i <br />Z <br />2 <br />W <br />c7 <br />1 <br />f <br />3. <br />4. <br />14. Special Handling Instructions and Additonal Information <br />F'r Nurnbw 3°,4!193 DDwmadH k: VW35 <br />ifkf* Ac"AMil <br />15. GENERATOR'SIOFFEROR'S CERDFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by the proper shipping new, and are classified, <br />packaged, <br />marked and labeledlplarerded, and are in as respects in proper condition for transport according to applicable international and national governmental regulations. If export shipment and I am the Primary <br />Exporter, I igMy that the contents of this consignment conform to the terms of the attached EPAAdnowledgmenl of Consent. <br />I certify that the waste minimization statement identified in 40 CFR 262.27(x) (if I am a large quantity genei or (b) Citi am a small quantity genera is true. 11, -- <br />eneraror r Offeror's nrrt yped Nape,.�..,✓�. signature ! Montht <br />year <br />V f <br />J <br />i <br />lI mtereahonal Shipments <br />❑ Import to U.S. ❑ Export from U5 Pon uY/exit: <br />Trans ner signature fore ods ant : �j' Da avi U.S.: <br />17. Transporter Acknowledgment at Receipt of Materials <br />T sooner P' a Raped Name 1 a <br />..Month;y <br />N <br />Q <br />Transporter Prmanuffyped Name Signature Month Day Year <br />C <br />H <br />Discrepancy <br />I18. <br />18a. Discrepancy Indication Space ❑ Quantity ❑ Tyo ElResidue❑ Pallial Rejection ❑ Full Rejection <br />Manifest Reference Number <br />So. Alternate Factity jot Generator) U.S. EPA ID Number <br />J <br />U <br />6 <br />rx- <br />Facili 'S Phone: ' <br />w <br />18c. Signature ofAllernale Facility (or Generator) Month Day Year <br />a <br />Z <br />N19. <br />Hazardous Waste Report Management Method Codes (re., codes for hazardous waste treatment, disposal, and recycling systems) <br />2. 3. <br />4, <br />1` <br />20. Designated Faclidy Owner a Operator. Certification of receipt of hazardous materials covered by the manifest except as noted In Item 18a <br />-Pd <br />dName Signature - 7 Month Day Year <br />��, �.1„�.. ev�f �,alivma evmmie ria ouealero. DESIGNATED FACILITY TO GENERATOR <br />