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v Form Approved.OMB No.2050-0039 <br /> typewriter.) Response Phone 4'Mabrifest O 3 TrackingNumber <br /> 11 J J K <br /> rla5se print or type, Form designed for use on elite(12-Pitch) 2 Page 1 of 3.Emergency <br /> RDOUS 1•Generator ID Number address) <br /> UNIFORM HA7�1 Generator's Site Address(ifdifferent than mailing <br /> WASTE MANIFEST <br /> 5.Generator's Name and Mailing Address <br /> M>t"BLOW <br /> 27 U.S.EPA ID Number <br /> CA 9M I <br /> Generators Phone: t;AR1U <br /> 6.Transporter 1 Company,aome__,,,,,�.� U.S.EPA ID Number <br /> 7.Tanspo <br /> AC era Company Name U.S.EPA ID Number <br /> 8.Designated Facility Name and Site Address <br /> raWr <br /> T�cay. <br /> 53175S �s 11.Total 12.Unit 13.Waste Codes <br /> U* 1o.Containers Quantity Wt.Nol. <br /> Facility's Phone: ing Name,Hazard Class,ID Number, NO. Type <br /> 9b.U.S.DOT Description(including Proper ShippP 352 <br /> 9a. and Packing Group(d any)) /� <br /> HM S0WWgst°In�debris) CDU <br /> 1. 1'!a1 FtCFtAM W8d9• <br /> O <br /> Ul Z 2' <br /> W <br /> C`7 <br /> 3. <br /> 4 <br /> 14.Special Handling Instructions and Additional Information \ i " / 3 <br /> �bf1i, W*BtsIA1 ` - '0) name,and reclassified.packaged, <br /> g.-1j _ ershipping <br /> the proper <br /> ort shipment and I am the Pr maty <br /> �aclare that the wntents of- consignment are fully and accurately described above by P <br /> S CERTIFICATION: I he, nditton for transport of according to applicable intemational and national govemmental regulations.If exp <br /> 15, GENERATOR'SIOFFEROR `"ects in proper co en to true. Month Day Year+� <br /> P and are in all resp enerator)or(b)(if I a a small quantity g <br /> marked end labeled) lacarded, consignment conform to the terms Of <br /> i am a�a 9e qua Acknowledgment <br /> wMdgment-of Consen. <br /> Exporter,I certify that the contents of this consig Signature <br /> I certify that the waste minimizationName statement identified in 40 CFR 262.270 l <br /> Generatorsl0fferors Printed(lype zit <br /> r l fl Export from U.S. Porf of entryle <br /> Dale leaving U.S.: <br /> J 16. <br /> international Shipments Import to U.S. Month w Year <br /> ? Transporter signature(for exports only): �'�'V <br /> of Materials Signature Year <br /> W 17.Transporter Acknowledgment of Receiptonth Day <br /> a Trensp er 1 P ted(fvped Name I, <br /> Signatu <br /> O <br /> n l <br /> Q Transporter 2 PnnledlTyped Name <br /> J�(L,tA Full Rejection <br /> O partial Rejection <br /> t— ❑Residue <br /> 18.Discrepancy 0 Type <br /> 18a.Discrepancy Indication Space Quantity Manifest Reference Number. U,S.EPA ID Number <br /> 18b.Alternate Facility(or Generator) <br /> Month Day Ye <br /> J <br /> U <br /> t4i Facility's Phone: <br /> W1Bc.Signature of Alternate Facility or Generator) clin s stems) <br /> F— 4. <br /> Q e codes for hazardous waste treatment,disposal,and recy 9 Y <br /> Z rt Manag ment Method Codes(i. <br /> D 19.Hazardous Wa le Repo 2 <br /> W 1 Month Day <br /> 1 of h dous en I <br /> vexed by the manifest except as noted In Item 18a <br /> 20.Designated Facility Owner or <br /> tor.Certification of receip Signature <br /> TION STA E(IF REQUIf <br /> Printeeyp <br /> ed Name <br /> DESIGNATED FACILITY T <br />