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Please print or type.(Form Guagned-for use on elite(12-pitch)typewriter) <br /> i Gencvamr ID Number FDnn Approved,OMB No.?060-0039 <br /> UNIFORM HAZARDOUS 2_Page 1 of 3 Emergency Resp,mc,i P r.,ne 4 Manliest Twidu 9 Number <br /> WASTE MANIFEST R f" "' "" ";� +� ��v <br /> 5 Generebr's Name and'datling Ldrass - �enar ms 3ila P:dd es J n'rfaent Shan r a r q eddrass' ,L I�.,, <br /> 3eneelm's Phone'. ` Id <br /> 8.Transporter 1 Company Nanta U.S.EPA ID Number <br /> 7 Transporter 2 Company Name . .... U.S.EPA ID Number <br /> 8.Designated Fadiity Name and Site Ad dress - U.S.EPA ID Number <br /> Factli. sPhon&t3+, <br /> ga. 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unft <br /> HM and Pecking Group(if any)) No. Type Quantity wtVol, 13.Waste Codes <br /> Lz ` <br /> w <br /> z <br /> Lill <br /> d <br /> 14.Sri--cial Handling lns¢ulrruis an(i AOXI ienal ln:ormetn; <br /> q. <br /> 1:. GENERATOR'SIDFFEROR'S CERTIFICATION: I hereby declare that the contends of this consignment are fully and accurately desobed above by the proper shipping name,and are Gassilled,packaged, <br /> marked and Iabeied(piacarded,and ate in all respects In proper condition for transport according to applicable Sierrad nal and MA at govemmenhl regulations.If export shipment and I am the Primary <br /> Exporter,I certify the:the contents of anis consignment conform to the terms of the aheched EPA AcknowiKtmentof d^`"""""°------'—^^-------..-- <br /> I ramify it's!the waste minimization statement iden6tied in 40 CFR 262.27(x)(if I am a large quantity generator)or(b{ am a syl quantity geeemd is true. <br /> Genendo?aMftees Pdniec,'T!,ped Name Signature Month Day Year <br /> J16.International Shipments <br /> Z ❑Import to U.S. ❑Export from U.S. Portonamylexit. _ <br /> Transporter sgnalure(far exports only): Dale hmong U.S. -- <br /> w 17.Transports,Ad<noveedgmem of Receipt N Materials <br /> OTrensponer t pdmedrTyped Name - Signaturei. t Month Day Year <br /> tor.i..r - --4r k•`.r _ _ _ <br /> ¢ transporter PrintediTyped Name Signature ManN Day Year <br /> 16.Discrepancy I <br /> 18a.Disaepancy Indication Spam El Qm fry, Type ❑Residue ❑Partial RCemmon FO R'action <br /> N <br /> Manliest Reference Number: <br /> 186.Nterralefaal8y(or Generator) US.EPA dO Number <br /> J <br /> V <br /> W FaclMy's Phew: <br /> w 16c.Sgnature ofAIMMael Faglity(or Generator) Monro Day Yom• <br /> 4 <br /> Z <br /> u0—f 19.Hammous Waste Reped Management Method Cotler Ila.,codes for hazaNa.�s waste tneaanant.disposal,and"reff systems) <br /> 3.w <br /> 1 20 Designated Facility Owner or Operator Cenriimtion of receipt of hazardous metedals covered by the manik et exmpt as noted In Item Im <br /> P6nWyp.d Name Signature Month Day Year <br /> EPA Foran 870042(Rev.3-05) Previous editions are obsolete. <br /> DESIGNATED FACILITY'S DOPY <br />