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Please print or type.(Form designed for use on elite(12-pitch)typewriter.) Form Approved.OMB No.2050-0039 <br /> UNIFORM HAZARDOUS 1.Generator ID Number 2 Page 1 of 3.Emergency Response Phone 4.Manifest Tracking Number <br /> WASTE MANIFEST <br /> SK <br /> f�{S <br /> 5.Generator's Name and Mailing Address Generator's Site Address(if different than mailing address) <br /> Generator's Phone: <br /> 6.Transporter 1 Company Name t_ .S.EPA ID Number <br /> 7.Transporter 2 Company Name ENVIRONME U.S.EPA ID Number <br /> 8.Designated Facility Name and Site Address U.S.EPA ID Number <br /> ygl u i <br /> Facility's Phone: <br /> ga 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit <br /> HM and Packing Group(if any)) No. Type Quantity Wt.Nol. 3.Waste Codes <br /> 1. <br /> O _ <br /> Z 2. <br /> w 1 <br /> t <br /> I <br /> 3 <br /> 4 <br /> 14.Special Handling Instructions and Additional Information <br /> 15. GENERATOR'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 /> marked and labeled/placarded,and are in all respects in proper condition for transport according to applicable international and national governmental regulations.If export shipment and I am the Primary <br /> Exporter,I certify that the contents of this consignment conform to the terms of the attached EPA Acknowledgment of Consent. <br /> I certify that the waste minimization statement identified in 40 CFR 262.27(a)(if I am a large quantity generator)or(b)(if I am a small quantity generator)is true. <br /> Generator'slOffemrs Printed/Typed Name Signature Month Day Year <br /> J 16.International Shipments <br /> E– ❑Import to U.S. ❑Export from U.S. Port of entrylexit: <br /> Z Transporter signature(for exports only): Date leaving U.S.: <br /> w <br /> 17.Transporter Acknowledgment of Receipt of Materials <br /> W Transporter)Printed)-Typed Name Signature Month Day Year <br /> O <br /> CL <br /> z Transporter 2 Printed/Typed Name Signature Month Day Year <br /> Q <br /> EX <br /> H <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space <br /> ❑ Quantity El Type ❑Residue ❑Partial Rejection Full Rejection <br /> Manifest Reference Number: <br /> >- 18b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> J <br /> U <br /> LL- Facility's Phone: <br /> W 18c.Signature of Alternate Facility(or Generator) Month Day Year <br /> Q <br /> z <br /> 19.Hazardous Waste Report Management Method Codes(i.e,codes for hazardous waste treatment,disposal,and recycling systems) <br /> LU 0 1. 2. 3. 4 <br /> 9n n—innatprl Facll{ty Ownpr nr Onpratnr Certifiratinn of rpceint of ha7ardnus malpnals covered by the manifest exceot as noted in Item 18a <br />