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Please p - <br />PUNl <br />W, ; <br />Far. <br />9a. <br />HM <br />0 <br />w <br />Z <br />W <br />15. <br />Ge <br />T <br />Ll 1( <br />Tr <br />01__ <br />a <br />Q Tel <br />I <br />�I <br />Form Approved. OMB No. 2050-0039 <br />1,_ARDOUS' <br />1. Generator ID Number <br />2. Page 1 of <br />y <br />3 �pqw RTonce Phone <br />4. Manifest T y Number <br />G B F <br />4.7 <br />NIFEST <br />� � ..T � � ' / <br />��::J.j . <br />U•�.d. �f <br />'ne and Mailing Address Generator's Site Address (if different than mailing address) <br />i 1 -- <br />�- <br />� � ; <br />omp8ny Ndrhe U.S. EPA ID Nur . <br />wwr F lou <br />firtdSot2 ent'i. <br />ompany Name <br />U.S. EPA ITN, ,:, <br />c itiftyy Naafi a d Sitaf gddress <br />fii1E5Liti3�?=3 <br />U.S. EPA ID Number <br />•���° Py �5n5V f�1 `�nr rl <br />�1htk31 • t 7rdhF1 I <br />DOT Description (including Proper Shipping Name. H <br />and Class, ID Number, <br />10.0 tainers <br />11. Total <br />12. Unit <br />13. Waste Codes <br />No. <br />Type <br />.king Group (ii any)) <br />Quantity <br />Wt.Nol. <br />PGf:� itdze�tk?tt�+ •..a�nSfEe „f+n� ir3ti. <br />fN'.i't1t►'�t <br />,,� �� ( <br />L71hi <br />� � <br />2" <br />I <br />dling Instructions and Additional Information <br />mPRCs + �_lrJOF- Ora 4.1A.9r 1 "t- >4L0-+1�it�� �r�.�k.1.r�� ,, <br />1)15�4� V. il.r#1 `{ <br />DR'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 />,id labeled/placarded, and are in all respects in proper =dition for transport according to applicable intemational and national governmental regulations. If export shipment and I am the Primary <br />-. I certify that the contents of this consignment conform o the terms of the attached EPA Acknowledgment of Consent. <br />that the waste minimization statement identified in 40 C F R 262.27(a) (if I am a large quantity generator) or (b) (if I am a small quantity generator) is true. <br />v <br />aror's Printed(fyped Name Signature Month Da� Year <br />1 i r <br />Shipments <br />❑ Import to U.S. El Export from U.S. Port of entry/exit: _ <br />:nature (for exports only): I Date leaving U.S.: <br />Acknowledgment of Receipt of Materials <br />Month D Y r <br />mted/Typed�N Signayrre <br />t <br />- <br />)ndr 2 rtnt drryped Name Signature Month Day Year <br />r <br />l <br />cy Indication Space El Quantity ❑ Type ❑ Residue ❑ Partial Rejection El Full Rejection <br />Manifest Reference Number: <br />r acility (or Generator) <br />U.S. EPA ID Number <br />�hnne: <br />Month Day Year <br />of Alternate Facility (or Generator) <br />i <br />s Waste Report Management Method Codes (i.e., cod for hazardous waste treatment, disposal, and recycling systems) <br />- <br />2 <br />3 <br />4. <br />Facility Owner or Operator: Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a <br />signated Month Day Year <br />4) <br />e ttions are obsolete. ; <br />TRANSPORTER'S COPY <br />