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a <br /> Now <br /> 4Y <br /> /designed for use on elite(12-pitch)typewriter.) Form Approved.OMB No.2050-0039 <br /> 1.Generator ID Number <br /> RDOUS 2.Page 1 of 3.Emerge�pResponse Phone 4.Manifest Tracking Number <br /> NIfEST t:x�l; t; r ) r. ) 8f., l `- 9-4 46 Q830654 JJ K <br /> oes Name and Mailing Address Generator's Site Address(if different than mailing address) <br /> 446 N t4�t-1R(,*A <br /> Generator's Phone: NI".0 -4�'g`'y <br /> 6.Transporter 1 Company Name U.S.EPA ID Number <br /> } fps it ('i t. YrI,tE.j� t',r1i31',';it .7 )}'i._il <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 /> j"d14l,�t.f'.1f �� '`itAflit`,fw Ri:.l.:salu(_;tl 'i f �4trfa! Y( <br /> Facility's Phone: l f100) 499--7-1.q r <br /> ga 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit <br /> HM and Packing Group(if any)) No. Type Quantity Wt.Nol. 13.Waste Codes <br /> h'i t A re:U MA I i:< <br /> o <br /> Z 2. f_ - vr4.. {re t• ., t,..y y ! S t <br /> LLJ <br /> 1k-itJ iVs--r i i i F£fi3}. t 11sf �+ lad#1];:C►_� <br /> =Z-J ------ -1 <br /> 3. <br /> 4. <br /> 14,Special Handling Instructions and Additional Information <br /> 4b] ) r'�V# k3-.Y9 -9,b2°..1..�G�,�.._j.a.;:i.:t',a� <br /> (d.I"W;;.;a, l�r0f"rf LEL"", & PTO a;I XVVV f.",1. if EMERGENCY C.011,11ACT 4 PIM( Lvf}rl.fFfaK: <br /> f f4i#k 90, ) 1?8 <br /> i ft{Si•f':'at 1;1f1,E¢"i!2 .t. f�rf^il..}lith:. , 1:-13k0l- 77V,'i,..61 ,Z <br /> 15. GENERATOR'SIOFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by the proper shipping name,and are classified,packaged, <br /> marked and labeled/placarded,and are in all 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 cerlity that the contents of this consignment conform tor the terms of the attached EPA Acknowledgment of Consent. <br /> I certify that the waste minimization statement identified in 40 CFR 262.27(a)(if I am a large quantity generator)or(b)(if I am a small quantity generator)is true. <br /> netator's/Offefprs Pnnted/Typed Na, a M n ay Year, <br /> -J 1 16.International Shipments <br /> z ❑Import to U.S. ❑Export from U.S. Port of entry/exit: <br /> Transporter signature(for exports only): Date leaving U.S.: <br /> W17.Transporter Acknowledgment of Receipt of Materials <br /> Transported P.rinted[Typed Name ____ - Signature Month, Day . Yq?r. <br /> a � fl. f /Y _ /F' fir' f r✓ <br /> to <br /> ZZ Transporter 2 Printedffyped Name Signature Month Day Year <br /> t- <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space ❑ Quantity ❑Type <br /> ❑Residue ❑Partial Rejection ❑Full Rejection <br /> Manifest Reference Number: <br /> 18b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> V <br /> Facility's Phone: <br /> LL, 18c.Signature of Alternate Facility(or Generator) Month Day Year <br /> Q <br /> Z <br /> F) 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> 0 1. 2. 3. 4. <br /> 20.Designated Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a <br /> Printed/Typed Name Signature Month Day Year <br />