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Please print or type. (Form designed for use on elite (12-aitchi Ivoevwi <br />c,,.,. A.,.,..,,,..a nU. u.. 1ncn nnon <br />"""' "" "`"" I 'DESIGNATED FACILITY TO DESTINATION STATE (IF REQUIRED) <br />1. Generator ID Number <br />UNIFORM HAZARDOUS <br />2. Pa 1 of <br />9 <br />3. Emergency <br />gency Response Phone <br />4. Manifest Trackin Number <br />WASTE MANIFEST A�� � 5 <br />Z�-Lf6 -5lO70 <br />000358856 FLE <br />51 Gener tor' Name and Malin dress t[N Generatofs She Address (if tliRerent Nan mailing address) <br />OA 4V)39dGp Y wV41F . �2An' xrc/2—J7A7rorJ <br />lS/o E.blA`lduary Ai�� /�frn/YLA �3y� Cauc�t.a.F /L� <br />10°1 - '`✓ - 9 � (./z 9�✓ i� <br />Generatofs Phone: 20'1- <br />Generm't�0' <br />6. <br />6. Transporter 1 ompany Name <br />U.S. EPA ID Number <br />Ct.zArJ J14180al) t4gh v 3ai 3a7-�5v <br />7. Transporter 2 Company Name U.S. EPA ID Number <br />8. Designated Facility Name a She lore s U.S. EPA ID Number <br />A,j-AodC <br />tO zor�1c0g52o6 <br />aulity's Phone: - - ZZ, jjz -712 <br />9a. <br />91b. US. DOT Description (including Proper Shipping Name, Hazard Class, ID Number, <br />10. Containers <br />11. Total <br />12. Unit <br />HM <br />and Packing Group (I any)) <br />Quantity <br />WtNoL <br />13. Waste Codes <br />No. <br />Type <br />/e, C� 1 r.r'r v 1�1 j4A1$7?3 W- <br />/4rC1fJ//o'.g:)04!`7 <br />t3'% <br />60rz <br />7vls7ar�rii1�/y�1 <br />Cti'� <br />Ulu <br />`2.ypLG <br />/ AQ✓r1 <br />61z <br />PIP 9 1? <br />1VI7 <br />t- cspo✓eor 5 <br />"�[YG?j <br />6e <br />Q (pANiI6/ y5 <br />— <br />�O <br />� es <br />S!W <br />!�/, <br />/rail <br />/,(nt�C/{✓ <br />�l i pr <br />14. Special HandlinIncandesce <br />15. GENERATOR'S/OFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accuratelydescnbed 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 ana'national governmental regulations. If export shipment and I am the Primary <br />Exporter, I certify that the contents of this consignment conform to the tens of the attached EPA Acknowledgment of Consent. <br />I certify that the waste minimization statement identified inJI0 CFR 262.27(a) (U I am a large quantity generator) or fj IT I am a small gen rator) is he. <br />Genyrator' OUem 'nteNfyped NanEjf igna ure on ay Year <br />f'� <br />Q. y <br />/9 "-V w t <br />-s <br />Z <br />16. International Shipments <br />1:1 Import to U.S. ZI Export ham S. Port of entry/exit <br />Transporter signature for exports only): Date leavin U.S.: <br />w <br />17. Traspode Acknowledgmentof Receipt of Materials <br />a <br />Trans der rimuclTypetl me ignatur on ay ear <br />` <br />Z <br />n poder2 nnted/Typetl Name gn ure Monty Day ear <br />F- <br />} <br />18. iscrepancy <br />life. Discrepancy Indication Space ❑ Quantity ❑T e <br />yp El Residue ❑ Partial Rejection ❑Full Rejection <br />Manifest Reference Number <br />18b. Alternate Facility (or Generator) <br />U.S. EPA ID Number <br />J <br />U <br />ri <br />Fagbl's Friona: <br />-or <br />w <br />Q <br />18c. Sgnature oIAlternate Facility Generator) <br />Month Day Year <br />z <br />19. Hazardous Waste Report Management Method Cortes (i.e., codes for hazardous waste treatment disposal, and recycling systems) <br />0 <br />1 <br />2. 3. <br />4. <br />20. Designated Facility Owner or Opeeraator: Certification of receipt of hazardous materials covered by the manife except a - in em 18a <br />PnnteNTyped <br />Name s^y Sig tzar Month Day Year <br />[nm. 8700 <br />ffCPA <br />22 % � no' 4/op•..iA.:_L_..au:--- _._ o <br />"""' "" "`"" I 'DESIGNATED FACILITY TO DESTINATION STATE (IF REQUIRED) <br />