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. �c <br />Please print or lupe. fForVfIM€'slon�d for use on elite f12-oit6. sw writer.). <br />Form Annrnved. OMR No 2050-0039 <br />trA rorm oruu-zz (nev. 3-ub) rrevlous saloons are oosolete. _ i 1 DESIGNATED FACILITY TO GENERATOR <br />rn <br />UNIFORM HAZARDOUS 1. Generator ID Number <br />WASTE MANIFEST CN �i <br />2. lodge i of <br />3.Emeigen Resogse Phone <br />4. Manifest Tmc�kiin Number <br />F L E <br />5. Generators Name and Mailing Address C1 y,U,, K y�l b(� n„1 ��, Generators Site Address (if different than mailinoVaddress) <br />?Do U11i Co. \It V tNA lf�) `�Grl �CxiC{�Ill �rU �4(dl$f{1010 kata(dcuS <br />?Do <br />F ►P (,n p (��' ` Wk TQC 111 i 1+ <br />t\' H q.5auitJtl �UJ.� Kk `.51 YI"Pf- <br />Gen�tdrs Pho�ii� <br />1 <br />. mnsporter 1 ompany Name U.B. EPA ID Number <br />l <br />1 <br />ie 11 i <br />7. Tr sporter 2 Company Name 11 - U.S. <br />EPA ID Number <br />B.Oesignated Facility Name and Site Address U. ID Number <br />Glieco 06(bor5 E.nvtrunme��c>( Svc. <br />3ogi R Menu t) C (rc IL <br />`, <br />Facility's Phone: o r -' 1 r ,t\] \ t� 0 l vi-, <br />9a <br />HM <br />9b. U.S. DOT Descripfien (including Proper Shipping Name, Hazard Class, ID Number, <br />and Packing Group (if any)) <br />f 0. Containers <br />11. Total <br />Quantity <br />12. Unit <br />Wt.Nol. <br />13. Waste Codes <br />No. <br />Type <br />ce <br />1 rlatIlrluxhiit, (-t.0 , N <br />A <br />���,��►,t,,r�c,t'Lne <br />Uc�T SP-tilody?GerS:ia?L�F:CH(�bas} <br />QCA <br />3. ln+ Re I ed tW� tral, 5ji W) idb3, PG <br />X <br />X uF:c yx40(, <br />4. <br />14. Special Handling Instructions and Additional mention <br />i.)Cc X551�n1 a•)CHaL10- od5xr1) ,F °3.}CtW140iva4 -k5s <br />l waii 50"1" C <br />15. GENERATOR'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 Iabeledlplacarded, and are in all respects in proper condition for transport according to applicable intemabonal and national govemmental regulations. If export shipment and I am the Primary <br />Exporter, I certify that the contents of this consignment conform to the terms of the attached EPAAcknowledgment of Consent. - <br />I certify that the waste minimization statement identified in 40 CFR 262.27(a) (if I am a large quanfity generator) or (b) (ff I am a small quantity generator) is true. <br />Gernerators/Offerm'sPrinterIfTyped Name igna ure%u on ay ear <br />Tam 1 W 15 o7 <br />-r <br />i <br />16. International Shipments <br />❑ Import to U.S. ❑ Export from U.S. Pod of entry/exit: <br />Transporter signature for exports only): Date leaving U.S.: <br />w <br />17. Transporter Acknowledgment of Receipt of Materials <br />Transporter 1 PrintedlTyped <br />MiI�� <br />Name —91 —9nMonth Day 79ar <br />i p <br />N <br />c 163 1 /S <br />G <br />Transporter 2 Prinledrryped Name ignature Month Uay Year <br />Y <br />F <br />;, IA 7 <br />18. Discrepancy <br />1 Be. Discrepancy Indication Space <br />❑ Quantity ❑Type ❑Residue ❑Partial Rejection ❑Full Rejection <br />Manifest Reference Number: <br />18b. Alternate Facility (or Generator) U.S. EPA ID Number <br />J <br />U <br />Q <br />r+- <br />Facility's Phone: <br />18c. Signature of Alternate Facility(or Generator) Month Day Year <br />a <br />z <br />19. Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste treatment, disposal, and recycling systems) <br />G1 <br />, .. <br />2. <br />3. <br />4. �. <br />20. Designat- Facility Owner or Operator::kation of receipt of, materials covered by the manifest except as noted in lie a <br />' <br />PnntadTvpndNRme Signatprb. \ l• . i ,Monty Day Year <br />trA rorm oruu-zz (nev. 3-ub) rrevlous saloons are oosolete. _ i 1 DESIGNATED FACILITY TO GENERATOR <br />rn <br />