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Form APProved.OMB No.2050 0039 <br /> 4.Mo e�T3 k5g6 7 5 0 9 ,1,1 K <br /> eWrltet.) Response Phone <br /> 2- itch)tYp 2 page 1 of 3.Emergency <br /> ease print or type•(Form designed for use on elite( 2-p <br /> itch), <br /> Generator ID Number address) <br /> UNIFORM H �.•rt Ol1S Generators Site Address('d different than mailing <br /> WAS c idIANIFEST <br /> 5.Generators Name and Mait g Address <br /> U.S.EPA ID Number <br /> 2.278 •- cmMoomio <br /> , <br /> CA <br /> Generator's ph°e U.S.EPA ID Number <br /> 6.Transporter 1 C mpanyName 8 10V ... 77036 <br /> Cghloffie ErvvtWm U.S.EPAID Number <br /> 7.Transporter 2 Company <br /> �Name t o m 4 �ADW703000 <br /> 6.Designated Facility Name and Site Address <br /> Wow T�Co�P 11.Total 12.Unit 13.Waste Codes <br /> 53715 5 . <br /> LJD6Pr�li�&VMe QQ18 10.Containers Wt.NolType Quantity <br /> Facility's Phone'. Proper Shipping Name,Hazard Class,ID Number. No. PZ <br /> 9b.U.S.DOT Description(including P CF 2 O <br /> 93. if an �deb"IS) O0 l v <br /> HM and Packing Group( Y) w�'��WsstS`� <br /> 1. ��� <br /> O <br /> W 2. <br /> Z <br /> W <br /> 0 <br /> 3. <br /> 4. <br /> ERG#171 <br /> i <br /> Special Handling Instructions and Additional Information Y� � � <br /> 14.Sp plesbc bue�,�m ieked are classified,packaged, <br /> ''••�e& the roper shipping name, <br /> S.•�e��15� ulations.If export shipment and I am the Primary <br /> nment are fully and accurately described ab a ental reg <br /> I hereby ort according to applicable intemational and national g Year <br /> CERTIFICATION: declare that the dontenls of this ding <br /> m°�l Consent. enerator)is true. Da <br /> proper er condition for transport mall quantity g MO�� <br /> 15. GENERATOR'SIOFFEROR'S and are in all respects fn p P b (if I am a <br /> Identified in 40 CFR 262.27(a)(if I am a lar <br /> qu�n6ry generator)or O( , <br /> marked and labeledlplacarded, Sign ure <br /> Exports <br /> r I certify that the contents a e in nt tae ent conform to the terms of the attached EPAAcy e e 9 <br /> wtity that the waste minimization statement <br /> to <br /> Gen r oeslofferoes pit ted ed� ILport of entry--� — -— lexit: <br /> a <br /> �rQ\ ❑Export from U•S• Date,leavf U.S.: <br /> e a <br /> MonthDay Y <br /> 16.International Shipments <br /> Import to U.S. 0' � U' <br /> Transporter signature(for exports only): Signature Month Day Ye <br /> Acknowledgment of Receipt of Materials <br /> Tr Transporter <br /> W Name D 1 2 <br /> anspp t � Signature <br /> O <br /> a <br /> rintedlTyped Na e ❑Full Rejection <br /> Z Transporter mro ` partial Rejection <br /> Q <br /> r,Y ❑Residue <br /> r <br /> B.Discrepancy ❑ ❑TYpe <br /> Indication Space Quantity Manifest Reference Number. <br /> 18a.Discrepancy U.S.EPA ID Number <br /> 18b.Ntemate Facility(or Generator) <br /> Month Day <br /> J <br /> V <br /> ua FaciliVs Phone: or Generator) <br /> W18c.Signature of Alternate Facility l osal,and recyci n9 systems) 4 <br /> C des for hazardous waste treatment,disp3 <br /> Z <br /> Management Method Codes(i.e.,co <br /> N19.Hazardous Waste sport Manag 2 Day` <br /> LU 1 Is covered by the manifest except as ndad in Item 18 <br /> Month <br /> azardo mat Signature t <br /> ner or erator.Certification of receipt ION STATE OF REG <br /> I 20.Designated Fatality AC -ro DESTINA <br /> PrintedliypedName nGSIGNATED <br />