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Please print or tvpe. (C=orm designed for use on elite (12-nitch) tvnawritpr) <br />u,,, tr.— �-4rlumua Lufflullh dor. unsaiete. GENERATOR'S INITIAL COPY <br />i nppuvcu. vino ivu. 4VOV-UVJ2 <br />UNIFORM HAZARDOUS 1. Generator ID Number 2 Page 1 of 3 Emergency Response Phono 4. Manifest Tracking Numbor <br />e I C <br />WASTE MANIFEST :. _ + , r f r• - ., f LC <br />`. Generator's Name and Mailing Address Goneralor's Site Address (if different than mailing address) <br />Gnnorefcrs Phone: <br />n 1 ransperler 1 Company arae U 5. EPA ID Number <br />7 Transporter 2 Company Name U.S. EPA ID Number <br />d Dennatcd Facility Name and Site Address U.S LPA ID Number <br />A. ! <br />Faali 's Phone: <br />ga, <br />9b U.S. DOT Description (Including Proper Shipping Name, Hozard Class, ID Number, <br />10. Corainers <br />11. Total <br />1 J Un't <br />HM <br />and Packing Group [if any)) <br />Quantity <br />Wt.Nnl <br />13. Waste Codes <br />No, <br />Type <br />1. Ntort ;1'.-T:A U61<.f:wil"kr 7f kh.. <br />0 <br />- <br />w <br />Z <br />2 �•,�:,ti RCR i i LAW-Mdma Oita► *h ` tu*d of €il ret i.y <br />3. <br />i <br />4 <br />i <br />14 Speaal Handling Instructions and Additional Information <br />0 7- <br />15. GENERATOR'SIOFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately doscribed above by the proper shipping name, and are classified, packegvd, <br />marked and labeled/placeided, and are in all respects in proper wridilion for transport according to appkcable international and national governmental regulations. If export sh pmerd and I am the Primary <br />Exporter, I cer5fy that the contents of this consignment conform to the lams of the attached EPAAcknowledgment of Consent - <br />I certify that the waste minimization statement Idenlifud in 40 CFR 26227(a) (if I am a largo quantity generator) or (b) (if I am a small quantity generator) is true. <br />Generalor'siORvro s Printed/TyFmame gnatury957 ay ear <br />- <br />-J <br />Z <br />16, International Shipments � � <br />❑ Import to 11 S L-_1 txpw from U.S: Port of entrytaxit <br />— <br />_ <br />Transporter si ature for exports only) Date leaving U.S.- <br />IX LU <br />17. TransporterAckndwledgmenf of Receipt of Materials <br />F- <br />Transporter 1 Printed ype0 Naft Signature <br />5 nth ay Ycar <br />y� <br />' <br />t— <br />Z <br />Transposer 2 Pnnledffyped Name ulnatur� -- 1 _s r Month Day f7ear <br />1d Discrepancy <br />lira Discrepancy Indication Space ❑ Quantity ❑Type ❑Residue Partial Rejection ❑Full Rejection <br />Manifest Referen"x Number <br />19b. Altemate Faclllly (or Generator) U.S. EPA IU NumW.r <br />U <br />Q <br />LL <br />Facilin/s Phone <br />it <br />� <br />18c. Signature ofAb.rnalo Facility or Generator) <br />Y ( Month Uay Year <br />Q <br />Z <br />19. Hazardous <br />Waste Report Management Method Codes (.e., codes for hazardous waste treatment, disposal, and recycling systems) <br />UJ <br />O <br />1 <br />2 <br />3. <br />a. <br />20. Designated Facility Owner or Operator. Certification of receipt of hazardous materials covered by the manifest except as noted in Item 10a <br />printed/Iyped Name Sitlnalury Month Day Year <br />u,,, tr.— �-4rlumua Lufflullh dor. unsaiete. GENERATOR'S INITIAL COPY <br />