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Please print or type. (Form designed fnr use nn alite 09-nirr,..i <br />r <br />UNIFORM HAZARDOUS <br />1. Generator ID Number <br />2. Page 1 of <br />3. Emergency Response Phone <br />viiunNNivvay. VIVID rvu. Luou-vva� <br />4. Manifest Tracking Number <br />WASTE MANIFEST <br />- „ -I, ^ . " JJK_ <br />5. Generator's Name and Mailing Address Generator's Site Address (if different than mailing address) <br />Generator's Phone: <br />6. Transporter 1 Company Name U.S EPA ID Number <br />• <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 />Facility's Phone: <br />9a <br />9b. U.S. DOT Description (including Proper Shipping Name, Hazard Class, ID Number, <br />10. Containers <br />11. Total <br />12. Unit <br />HM <br />and Packing Group (if any)) <br />Quantity <br />WtNol. <br />13. Waste Codes <br />No. <br />Type <br />O <br />t <br />w <br />z <br />z. <br />L <br />c9 <br />3. <br />4. <br />14. Special Handling Instructions and Additional Information <br />-4 _U01 _U011; 471 i _rdk..7LL .:L1 <br />.{ZESn:i7 IIA `+--i7''FF-^L <br />:-'....:..a._.:_..- �• i..?.+ ...-MW^:4�4.. flb^ �F' 8 tM�y v'AI", •� f� l�-• lufT^f-^.-. _ ._m. T.._ .-,...,.....,.. �.._.._._..-,.._..._..... _ <br />.�...�-.�....-.� <br />15. GENERATOR'S/OFFEROR'S CERTIFICATION: I hereby declare thafthe contents of this consignment are fully and accurately described above b)0he 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 certify that the contents of this consignment conform to the tenns:ofIhe 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 />Generator's/Offeroes Printed/Typed Name - _ .._ Signature.- _ _ _ _ Month Day Year - <br />J <br />Z <br />16. International Shipments <br />❑ Import to U.S. ❑ Export from U.S. Port of entry/exit: <br />Transporter signature (for exports only): Date leaving U.S.: <br />LM <br />LM <br />17. Transporter Acknowledgment of Receipt of Materials <br />IX <br />Transporter 1 Printed/Typed Name Signature Month Day Year <br />O <br />QTransporter <br />2 Printed/Typed Name Signature Month Day Year <br />H <br />18. Discrepancy <br />18a. Discrepancy Indication Space <br />Quantity ❑Type El Residue ❑Partial Rejection ❑Full <br />Rejection <br />Manifest Reference Number: <br />18b. Alternate Facility Generator) <br />(or U.S. EPA ID Number <br />J <br />U <br />Facility's Phone: <br />w <br />18c. Signature of Alternate Facility (or Generator)Month Day Year <br />Q <br />Z <br />7) <br />19. Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste treatment, disposal, and recycling systems) <br />LU <br />p <br />1. <br />2. <br />3. <br />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 />PrintedlTyped.Name Signature Month- Day Year <br />orru . -LL <ncv. o -vu/ rrevruus eumans are oosoleie. ZEEiGNATED FACILITY TO GENERATOR <br />