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PIP-99se I)hnL or tvoe. (Form desioned for use on elife 117•nifrhl tvn—rd- 1 <br />zPA "rm 8100 ZZ (Nov. 3-05) Previous editions are obsolete. GENERATOR'S INMAL COPY <br />- - i U+Iar IJYI UVUU. VIVID IYU. 4000-UUa-d <br />UNIFORM HAZARDOUS 1. Generator ID Number 2. Page 1 of 3. Emergency Response Phone 4. Manifest Tracking Number <br />WASTE MANIFEST -11.TSibr a ?.Fsl11t; r .t7Q "t•r 0- 1 0 2 Q 4 FLE <br />?raw <br />5. Generator's Name and Mailing Address Generator's SiteAddr= Cif d 5reht than mailing address) <br />- lith j.l{pR5 <br />, S. Is �1f3�?ttVR ��il1.QtifR'f <br />r t <br />S <br />Gznzrntoes '4 <br />b ransporlor 1 om�af y erne U.S. EPA ID Number <br />_ ...- 4 TMWP d Im. (Sv) <br />I Transporter 2 Company Name US [PAID Number <br />. .." p4w-wySte,L-M <br />8 Designated Facility Name and tile Address U.S. EPA IG Number <br />_ <br />A <br />Facility's Phone: <br />ya. <br />gb. 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 (I any)) <br />Quantity <br />Wt-Nnl <br />13. Waste Codes <br />No. <br />Type <br />Nctfl-E{i..f`.A c h4Ye3f(➢Rxil <br />0O <br />- <br />W <br />Z <br />2. <br />W <br />I <br />� I <br />_ <br />4. <br />f <br />i <br />i <br />14 Special Handling Instructions and Additional Information <br />fifflWCAY <br />17 GENERATOR'SIOFFEROR'S CERTIFICATION: I horuby declare that the contents of this consignment are fully and accurately described above by the proper shipping name, and are da:;si5ed, packaged, <br />marked and labdedlplacarded, and are in all respects in propercondition for transport according to applicable international and national governmental regulations. If export shipment and I am the Primary <br />Exporter, I certify that the cbnlonts of this consignment conform to the terns of the anachcW EPA Acknowledgment of Consent <br />I codify that the waste minimization stalement Idenllried in 40 CFR 282.27(a) (f I am a large quantity generator) or (b) (d I am a small quantity generator) is true. <br />Generators/Offerors Pnntedf Iyped Name Signature monm Day ear <br />�j <br />1`- <br />18 International Shipment; <br />❑ Impart to U.S. ❑ Export from U.S. ?ort of entry/exit <br />z <br />transporter signature (for exports only) Date leaving U.S.: <br />w <br />17 Transporter Acknowledgment of Receipt or Materials <br />Transporter 1 Nnted/Typed Name Signature Month Day Year <br />QTransporter <br />2 Prinledityped N.rmc Signature MonM )ay Y. -Ir <br />IX <br />18. Discrepancy <br />18a. Discrepancy Indication Space II��tI <br />Quantity ❑Type II Residue ❑Partial RgjecUon 117 Full Rejection <br />Manifest Reference Number <br />18b. Altemate Facility (or Generator) US EPA ID Number <br />J <br />U <br />Q <br />�+- <br />Facility's Phone. <br />W <br />18c. Signature of Alternate Facility (or Generator) Month Day Year <br />uj <br />15 Hazardous Waste Report Management Method Codes (7 e., codes for hazardous waste treatment disposal, and recycling system) <br />W <br />D <br />1 <br />2. <br />3 <br />4 <br />20. Designated Facility Owner or Operator Certification of receiptof hazardous materials covered by the manifest :xcept as, noted In Ilem 1&I <br />-11 <br />?nntedrTvped Name Signature Month Day yen <br />zPA "rm 8100 ZZ (Nov. 3-05) Previous editions are obsolete. GENERATOR'S INMAL COPY <br />