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please print or type (Form designed for use on elite (12 -pitch) , Ater.) <br />Form Approved. OMB No, 2050-0039 <br />""'""""" """'""" "'"""'"" DESIGNATED FACILITY TO DESTINATION STATE (IF REQUIRED) <br />UNIFORM HAZARDOUS 1. Generator ID Number <br />2. Page 1 of <br />3. Emergency Response Phone <br />�() <br />4. Manifest Trackin Number <br />000358785 FLE <br />WASTE MANIFEST `i pO <br />5. ecrla[orn(yName `Jcc MailiU l�res6n�k AtTM: v m6kA Wry= ite An mg (iltliXshoo innHoubeaddress) <br />�d �idao",^C� <br />Fac111}, JM^^'�t Vwo71� <br />f:WNZ q . RA Bri e p Si rec�F <br />10f'if�f"i" <br />Genera one: <br />6. Transporter 1 ComDan Name U.S. EPA ID Numher <br />7. Transposer 2 ompany Name U.S. EPA ID Number <br />8. slg ad Fadliry yams and Sit A`dd�ss LLS. EPA ID Number <br />_nau, ame2GgeAdd u• SeF1 ,Ce5 <br />g�al F%NerkWn l-trc�� <br />EIdo O)R r I1-130 <br />Facility's Phone: y R� <br />9a. <br />9h. U.S. DOT Description (including Proper Shipping Name, Hazard Class, ID Number, <br />and PacNing Group (if any)) <br />10. Containers <br />11. Total <br />Quantity <br />12, Unit <br />13. Waste Codes <br />HM <br />No. <br />Type <br />Wt.Nol. <br />or <br />1. lammahle I-f$ut "N o•S•,3, Un(99�, P� iC <br />RX <br />C9aIrne,qce}on�),�er5:lap,)CPF:lniigQ�9) <br />4 <br />2.�(n�- Relgl-etl '(Yla%e"rIa15,3,un�aco� PGS"' <br />� <br />X <br />C�cn-s�-�►�ay�,Cerr�y:«BJCPF: rtiy��cP) <br />F <br />ty <br />> <br />3. 1�k 1?�1Q}-ed (Y10.�er(G,1,3;u"n(ae3,aGiC <br />� <br />N <br />X <br />ry� <br />4. <br />14. Special Handling Instructions andA ditional Information <br />(.} (D�a9.I !--X55 ba) <br />-oc i 5c * Y, -'q i yd <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 labeled'placarded, 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, I Certify that the contents of this Consignment conform to the lens of the attached EPAAcknowledgmenl of Consent. <br />I certify that the waste minimization statement identified in 40 CFR 262.27(a) (if I am a large quantity generator) or (b) (f I am a small quandty generator) is hue. <br />GeneratorsJOffences PrinteciTyped Nametgna a on ay ear <br />I 1e- WlL dA la 13 U�v <br />F <br />Z <br />16. International Shipments <br />❑ Import to U.S. ❑ Export from U.S. Pad of enhylexil: <br />Transporter si nature for exports only): Date leaving U.S.: <br />TransporterAcknowledgment <br />W17. <br />of Receipt of Materials <br />a <br />Transporter 1 PnnledRyped Name igna ure Month ay Tear <br />�✓Y\"Nme <br />h\ �� 1 �l7 <br />QTransporter <br />PrinteMyped Name ig ure ont Day Year <br />K <br />r— <br />18. Discrepancy <br />lea. Discrepancy Indication Space El Quantity El Type ❑Residue ❑Partial Rejection ❑Full Rejection <br />Manrfesl Reference Number <br />F <br />led. Alternate Facility(or Generator) U.S. EPA ID Number <br />J_ <br />V <br />Q <br />LL <br />'s <br />Fauli Phone: <br />,may <br />Q <br />18c. Signature of Alternate Factlity (or Generator) <br />Month Day Year <br />2 <br />y19. <br />Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste treatment, dispoeal, and recycling Systems) <br />p <br />1. <br />2. <br />3, <br />4. <br />20. Designated Facility Owner or Operator. Codification of receipt of hazardous materials Covered by the manifest except as noted in Item 18a <br />1 <br />Pdnted(Typed Name Signature Month Day Year <br />pori <br />c....., e7nn nn rDo nn. D.....:,..... _aa <br />""'""""" """'""" "'"""'"" DESIGNATED FACILITY TO DESTINATION STATE (IF REQUIRED) <br />