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Please Drint or tvoe. (Form desianed for use on elite (12-6tch) tvoewriter.) <br />Form Aooroved. OMB No. 2050-0039 <br />'A homl b tw-22 (Hev. 3-n) Previous editions are obsolete. <br />DESIGNATED FACILITY TCI nPCTINI ATrnnr CTA?� r <br />UNIFORM HAZARDOUS <br />WASTE MANIFEST <br />1. Generator ID Nu er <br />L (� 0. � 3 -b <br />2. Page 1 of <br />3. Emergency Response Phone <br />(� } D j— <br />4. Manifest Tracking Number <br />000257466 M W I <br />5. Generator's Name and Mailing Address Generators Site Address (if different than mailing address) <br />� L oGA L M ATEK1 L MNn(Alrq LC7HCnIT LLC. (b�-t C, �1 <br />f 6 4 o, M, a f -p f'r77� t.t lw C1 ST ckTo� <br />5l <br />L-A -q 710S T\ V <br />Generators Phone: Ci10 L' <br />E. Transporter 1 Company Name U.S. EPA ID Number <br />LL IToN .1 uc� <br />7. Transporter 2 Company Name U S. EPA ID Number <br />B. Designated Facility Name and Site Address U.S. EPA ID Number <br />CLC-AI�I �A-�R� <br />zr,'oQ W LO EtP` ") QU7Tan1��L�a�,Cfl �32�� <br />�� �-b - 6 �-�_ A <br />Facility's Phone: <br />ga <br />9b. U.S. DOT Description (including Proper S ipping Name, Hazard Class, ID Number, <br />10. Containers <br />11 Total <br />12. Unit <br />13 b'Jas1e Codes <br />No. <br />Type <br />HM <br />and Packing Group (if any)) <br />Quantity <br />Wt.ft. <br />%SON-(LC�¢1 }};RZ-/i <br />pUS W�S�F��er-l0 <br />0oI <br />C-jj <br />2-0 <br />Y <br />Z <br />W <br />2. <br />3. <br />4. <br />14. Special Handl;ng Instructions and Additional Inform fion <br />pt?- L V- * C - 1i1 L r2- I <br />V P120 PCS rPC <br />15. GEN ERATOR'SIOFFEROR'S CERTIFICATION: <br />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 labeledrplacarded, and are in all res <br />cis in proper condition for transport accordicg to applicable international and national governmental regulations. If export shipment and I am the Primary <br />Exporter, I certify that the contents of this consign <br />nt conform to the of the attached EPA Acknowledgment of Consent. <br />terms <br />I certify that the waste minimization statement ide <br />tified 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 />Generators/Offerors Pr;M" <br />Signature Month Day Year <br />j <br />b a�kl <br />16. International Shipments <br />❑Import to U. Export from U.S. Port o(enlrylezit.• _ <br />— <br />transporter signature (for exports only): Date leaving U.S.: <br />W17. <br />Transporter Acknowledgment of Receipt of Materals, <br />iW <br />Transporter 1 Printed/Typed Name Signature Month Day ve=_r <br />O <br />a <br />QTransporter <br />2 Printed/Typed Name Signature Morth Day Year <br />K <br />r <br />18. Discrepancy <br />{� <br />18a. Discrepancy Indication Space ❑ Quantity ❑ Type ❑ Res due U Partial Rejectior. ❑ Full Rejection <br />Manifest Reference Number: <br />181b. Alternate Facility (or Generator) U.S. EPA ID Number <br />LL <br />Faality's Phone. <br />L <br />18c. Signature of Altemate Facility (or Generator) <br />Month Day Year <br />Q <br />Z <br />9 <br />n <br />19. Hazardous Waste Report Maragement Method Cods (i.e., codes for hazardous waste treatment, disposal, and recycling systems) <br />:1 <br />1. <br />2. <br />T- <br />14. <br />20 Designated Facility Owner or Operator: Certification f receipt of hazardous materials covered by -he manifest except as noted in Item 18a <br />Printed/Typed Name Signature Month Day Year <br />'A homl b tw-22 (Hev. 3-n) Previous editions are obsolete. <br />DESIGNATED FACILITY TCI nPCTINI ATrnnr CTA?� r <br />