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17 r <br />1 120 <br />Pr <br />EPA Fr. <br />Form dpqinnp.(i for use on Plitp. (12-nitr.h) tvnpwritf-r I <br />orm Moroved. OMB No, 2050-0039 <br />RDOUS <br />(I. Generator ID Number <br />I <br />tn�,rgenMTpoqse Wione 4. Manifes <br />-41'. V- <br />q Number <br />G B F <br />:IFEST <br />6 � t -- - 1 -.1 <br />li , : , ? <br />- <br />f" ... --Ir*-, -0 <br />Generator's Site -Address (if different than mailing addre <br />J1867 <br />5 3 <br />e anVailing Address <br />ri <br />r,r c <br />A N <br />U.S. EPA ID <br />'Af <br />II U.S. <br />rnpany Name <br />)mpany Name <br />Jji rAVj,,J11 fldress U.S. EPkI <br />se ROO p1s)4-1 <br />)OT Description (including Proper Shipping Name. azard Class, ID Number, 10. Containers 11. Total <br />Unit <br />13. Waste Codes <br />ing Group (if any)) No. Type Quantity <br />,.Not. <br />'VM,q Hai 1,4*n �,Vii4c i',toid DEFW;6,- 0 0 <br />Iling Instructions and Additional Information <br />tf-4,1f. <br />.b <br />f e:ft G Ill" <br />-A <br />RISIOFFERORIS CERTIFICATION: I hereby declare <br />that the contents of this consigner fully and accurately described above by the proper s, <br />name, and are classified, packaged, <br />labeled/plararded, and are in all respects in proper <br />condition for transport according to apphrable intemationaland national governmental regulations. ll <br />export shipment and I am the Primary <br />-ertify that the contents of this consignment conform <br />to the terms of the attached EPA Acknowledgment of Consent. <br />:he waste minimization statement identified in 40 C <br />262.27(a) (if I am a large quantity generator) or (b) lift am a small quantity generator) is true. <br />-or's Printed/Typed Name Signature, <br />Month Day Year <br />;hipments El Import to U.S. El Export from U.S. Port of entrylexit: <br />iture (for exports only). Date leaving U.S.: <br />Anowledgment of Receipt of Materials <br />Pd[Typ NameSI(j <br />-4 <br />t <br />Month Day Year <br />Le <br />rinted/Typed Name Signature <br />Month Day ear <br />Indication Space El Quantity El Type El Residue ❑ Partial R. <br />❑ Full Rejection <br />Manifest Reference Number: <br />Aity (or Generator) U.S. EPA ID number <br />f Alternate Facility (or Generator) <br />Month Day Year <br />taste Report Management Method Codes (i.e.. code; for hazardous waste treatment, disposal, and recycling systems) <br />4.J <br />2. 3. <br />adlity Owner or 0pprptor: Certification of receipt of $azardous materials covered by the manifet ex pt as noted in Item 18a <br />SigV tur <br />Month Day Year <br />Vl� <br />(Rev. 3-Ub) FreviMs eamons are obsolete. 1 1 <br />14 <br />TRANSPORTER'S COPY <br />