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trorm aesrgnea <br />roc use on u- ) typewruer.) - Form Approved. OMB No. 2050-0039 <br />M HAZARDOUS, <br />1. Generator t mb& 2. Page 1 of 3. Emergency Response Phone 4. Manifest Tracking Number <br />r5nertype. <br />E MANIFEST <br />C,. A l � . G 4 1 E• : 1 : eRft� 4w °s�� ��� � � � JJK <br />atorsName and Mailing Address Generator's Site Address (if different than mail g address) <br />Generators Phone: <br />6. Transporter 1 Company Name U.S. EPA ID Number <br />., <br />C A 0 C: _ 2 e i v's% <br />Z Transp xte, pany Name' <br />U.S. EPA ID Number <br />8. Designated Faculty Name and Site Address <br />U.S. EPA ID Number <br />Facility's Phone: -ri - 3 ! <br />9a. <br />96, U.S. DOT Description (including Proper <br />Shipping Name, Hazard Class, ID Number, <br />10. Containers <br />11. Total <br />12. Unit <br />HM <br />and Packing Group (if any)) <br />Quantity <br />WUVo[ <br />13. Waste Codes <br />No <br />Type <br />'r :.. r•t2+ :'ii�.'lV" KJ .�' <br />` :. i;,N-(JIFII 4", r ,... 4.Ut <br />Z <br />2. <br />1 <br />W <br />3. <br />4. <br />i �- <br />14. Special Handling, InstrycUorls ar)d Additional Info(mation <br />�_��. <br />} r4'i I v < r , r ri <br />'hi���4�w. 1 . " - +. .g. "i _f' _-'�">-Y<'... S,�,f, ii=vt.:`�:� `s�i� , i�� � �. � 7 I:' ij a�w •t` i a_ " <br />t -f!'- F!Tk i.3 ct', r#- %t1 �'ti,`�}�t`,,.3,(�i`. { 1 Fig tf?�i; i} (}(ii -rt `. s k j,P y-riPP!, > 4i r�.4i 3�it?T¢:C'sk ., t?!3�«4 Ei <br />15. GENERATOR'S10FFEROR'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(piararded, and are in all 4pects in proper condition for transport according to applicable international and national governmental regulations, if export shipment and 1 am the Prinray <br />Exporter, I certify that the contents'of thus nmentcornform to the terms of the attached EPAAckrawktdgment of Consent t , <br />I certify that the Waste minimization statement' entified in 40 CFR 26227(a) (d I am a farce quantity generator) or (b) (#I am a small quantity generator) is true. <br />GeneratorslOfferoes PdntgdlTyped Name Signore I f Month Day Year <br />J <br />i— <br />16.-Tritemational Shipments �✓- <br />❑ import toJ.S. LEI Export from U.S. 50of entryiexit: <br />Z <br />Transporter s gnature (for exports only): iDate Leaving U.S.: <br />W <br />17. Transporter Acknowledgment of Receipt of Materia Is <br />X <br />Transporter 1 Printed/Typed Name Signature Month Day Year <br />O <br />a <br />QTransporter <br />2 PdntedfTyped Name Signature _ Month Day Year <br />(1' <br />18. Discrepancy <br />18a. Discrepancy Indication Space ❑ Quail It Type Residue Partial Rejection ❑ ❑ ❑ etedon Full Rejection <br />Manifest Reference Number. <br />18b. Alternate Fadlo (or Generator) <br />U.S. FPA ID Number <br />J <br />U <br />tai <br />Facility's Phone: <br />18c. Signature of Alternate Facility fox Generator) <br />Month Day Year <br />w <br />Q <br />Z <br />-- <br />N <br />19 H- ;, rkvic Wacto Report M—q, ent Mdhod Cod— <br />(i.e., wdia ru: IrdzaroouS waste treatment, disposal, and recycling systems) <br />0 <br />1. <br />3. <br />14, <br />20. Designated Faality Owner or Operator. uffffimb4n <br />of feceipt of ha72tdous matenafs coveted by the manliest except as rated in Item 18a <br />PrntedriypedName ' Signature g Month Day Year <br />LYA Form ! /U0 -ZZ (ttev. "5t t'ravrous earrrons dqe uuxneie. r vm J IIY1 If— <br />v..•r " <br />