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Please Print or typ-e,(Form desii;ined for use on elite(12-pitch, Otor.) 477 /77 R, A/4-R60A/ I-JA Form Appr�,ved,CA,18 No.20�)-0039 <br /> UNIFORM HAZARDOU,9,, I.Generator ID Number 2.Page I of 3.Emergency Response Pho 4.Memdi4Tracklho Number <br /> WASTE MANIFEST <br /> ndMsiIlngA4drM GB <br /> -';.";ki GineraWs&19 Addrese(If dbrvnt than mailing Addrm) <br /> Generator'$Phone.-... <br /> 6-Trenaporter I Company Nsrm U.S.EPA 10 Number <br /> 7.TranSporter 2 Company Name U�i.hl'A 11J Number <br /> .8,Designated <br /> .facility,Name and Sb.Address U.S.VA ID Number <br /> Fadid('s Phone: <br /> 9a. Qb-U,S.DOT Desoription Ckxiudirig PWw Shipping Name,H079AJ Glass.10 Number, 10.Containers <br /> HM and Paddrig Group ff any)) -- 11.Total 12.Unit <br /> NO. Type Quentity VVI-Nol. <br /> LU <br /> R, <br /> 14.15perial A-endling Instmcilons;d Additionai'informedw \j L, U N I V I L- <br /> -PARTNIEN'T <br /> H r7:41 TH r)f- <br /> 15. GF-NEPATOFC310FFEROWS CERnFICATION: l'hereby declans that the contents of this WnSignMot am fully and accurately dawlbecl above by the proper sAlipping name,and are clawified,paGkoged, <br /> marked and lebeled/poarded,and are in all rasps*in Proper condition for transport according to VD11cableAsmatJorial and national gnvernm0tal regulations.If expcirt shipment and I am the Primmy <br /> EV01W,I certify that the contents of this consiginmend conform to the Wm$Of the attached EIIA Aeknowledgment of Consent <br /> I certify that the waste minimization statement identified in 40 CFR 262.27(a)fff I am a large q�an%generator)or(h)(if I am a 3mell quantity gan"or)is true. <br /> Generators/Offoroeo PrinWTyped Name S�naturs Month Day Yi 3r <br /> 16,lnWnaUon9l Shipmen <br /> t5 import to U.S. Ej Export from U.S. Port of entry/e)dL- <br /> Transporier sIgnature(for exports only): Dete leaving U.S,! <br /> 17,IrranspDrIerAdnowledgment OF Rewipt of Majerials <br /> LU <br /> I-- T, <br /> PrintediTyped Ner" Signature Month Day Ye ir <br /> aftne <br /> rm;s��2 pit N Signature <br /> Month Day 1'e ir..' <br /> 18. <br /> 18s.Discrepancy Indication Space El Quantity Type Residue Psrtia)Rejectlon EjF1jJl Rajecti-�n <br /> i8h.Alternate F2cillty(or Generator) Mandeal Reference Number <br /> V.S,EPA ID Number <br /> LL Facility's Phone; <br /> 18c.Signaiture ofAllernate Facility(or Genere" <br /> month DaV V,jr <br /> ZO <br /> 19.Hazardous M sto Re port Me nagement Method Codes(i.e.,cofts for hazardo us waste treaknent,dispml,and rscoiq systems) <br /> Notice.State Of California requires <br /> 20.Designated Fanilil�y Owner or Oper2tor:Cei-Ficatior of recalpt of hazardous material*wverid by the manifW cxogp(as now in Item 18a generator to photocopy and mail to <br /> iJrlrdgdrryped Name DTSC with 30 days: <br /> P-0 BOX 400 <br /> EPA Form$700-22 Rev.3-05) Previous edil;ons wig ob'scilptp. Sacramento,CA 95812-0400 <br /> n9moDAIrnovollumal J%0%�L <br />