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:h <br />Please orifi nr Wee`_ /Form dasioned for use on efltS,1?-oPo <br />,ewrfter.) <br />,n <br />Form Approved. OMB No. 2050-0039 <br />revlous e Ions are <br />4 <br />UNIFORM HAZARDOUS 1HGenirator lb Nurn r - <br />2. Page lyof <br />3, Emergenq ResponsePhone" <br />B I[ Trackin Number <br />4. M0anlf6035848FLE <br />603H8 4 8 <br />WASTE MANIFEST _ <br />5. Generators Name and Mailing Address JJ Generaors Site Address (9 different than mailing address) <br />Nil <br />'S4., Nil <br />(L. �r••1, [I LUGS}�, SIUl1 KAtki t•,,Oi ak NoLiice W",.,) <br />L. )l 1�1ri '3N� I "Lill) L'.U,i-Il)U`�E.�I'1GIL� (.l�`�(f` <br />Ct.). <br />y{s�•JQ <br />AC'h.1 L'A I: A. 1(d btS��� <br />Gen,;l6oShc,E <br />6. Transporter 1 Company Name U.S. EPA ID Number <br />U.S. EPA ID C/ r r?u n 9 1 rJ <br />7. Transporter C! /�nci/s' e /up A,-- TTr A✓7 T <br />/ (10 <br />8. Designated Facility Name and Site Address S. EPA ID Number <br />C�FQ,A hwbcr E r�utrc wvlf 14al eruicil <br />'Ac ,cidu ('fir. 1t"13c 7U "(� X17' ��11 L 40� -.. <br />Fadi s one: <br />9a. <br />9b. U.S. DOT Description (inducing Proper Shipping Name, Hazard Class, ID Number, <br />10, Containers <br />11. Total <br />12. Unlit <br />13. Waste Codes <br />No. <br />Type <br />HM <br />and Packing Group (If any)) <br />Quantity <br />WtNol. <br />O <br />,/ <br />1' 1: 1 ammai>I �/,u, d n.o•s. (Th •Tners PFi fdleum <br />17,5Et11c�+��C Hviik% uni9431 h��i7r ��rri•.IT—f'i� <br />(�� <br />_ <br />) <br />'Y-, <br />i 1 <br />N Iv. <br />+4 <br />Ke"icAted CTlak�rlc�lC�a'rnt �1�"hnnerU,► <br />Xz'�u,n� <br />P)a fA pant-CNHW)131u111'Ll 3 a U cbcT 1.11 <br />14) <br />3. <br />4. <br />14. Special Handling Instructions and Additional Intonation <br />1•)CL11 IC)<o'd 1 _� 'CSr;�(1l •1.) C11 a4C (c _�- k 15C`_f <br />rCA, ler V5C b`'a ESUc,clz I'4 'mac <br />15. OENERATOR'SIOFFEROR'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 Iabeledlpiacarded, and are in all respects In proper condition for transport according to applicable international and national governmental regulations. If export shipment and I am the Primary <br />Exporter, ImNfy that the contents of this consignment conform to the terms of the attached EPA Acknowledgment of Consent. <br />I certify that the waste minimization statement identified In 40 CFR 262.27(a) (t I am a large quantity generator) or (b) (t I am a small quantity generator) is We. <br />Generatoreras Pninteof I yped Nameignaure - ay Year <br />�1 rytnt lE l� - � <br />z <br />16. International Shipments <br />- ❑Import to U.S. ❑ Exportfrom US, Pon of entrylexit: <br />Transporter signature for exports only): Date leaving U.S.: <br />w <br />17. Transporter Acknowledgment of Receipt of Materials <br />Transporter 1 Pdntee/Typed Name Signature on ay ear <br />'7 <br />N <br />l & ni i '> r I %� � - -4 I a <br />G <br />Transggrter2 �tedlryg/eQName Signora Man Day ear <br />18. Discrepancy <br />t <br />18a. Discrepancy Indication Space ❑ Quantity Type ❑ I ❑ Full Rejection <br />❑T El Portal Re ecton <br />Manifest Reference Number: <br />18b. Alternate Facility(or Generator) U.S. EPA ID Number <br />J <br />U <br />R <br />Faeih s P fine <br />W <br />18e Srgn redfAlfemate Facility (or Generator) 4"A Month Day Year <br />z <br />y <br />19. Ha4rqDus Waste Repon Mana emeet Method Codes (i.e:, onqasf for hazardous waste treatment, disposal, and recycling systems) <br />20. DesIgrr4qVadffty <br />Owner pr 0 for emficat' n of recei t of hazardous matedals e t e <br />t oted in Item 18a <br />Pr medfT <br />e-• imif i,_' ,3'.., a',: v S' a re... or <br />EPA <br />F 87 0 2 <br />R 3-05 P ' d'tt' ^ ^ ^ neerr_unrED FACILITY TO GENERATOR <br />revlous e Ions are <br />4 <br />