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Please print or type. (Form designed for use on elite (12 -pitch) dwriter.) <br />Form Approved. OMB No. 2050-0039 <br />crm rurr oruo-« knuv. ruo) rrewous eontuns are oosunne. <br />\ I DESIGNATED FACILITY TO DESTINATION STATE (IF REQUIRED) <br />UNIFORM HAZARDOUS 1. Generator D Number <br />r� <br />2. Page 1 of <br />3. Emu envy Response Phone <br />4. Manifest Trackln Number <br />000358821 <br />FLE <br />WASTE MANIFEST (,10 <br />�� - a'---6;7 <br />S. Generators Nameand Maili gAddre Generator's Site Address (if different than mailing address) <br />,7C�a97�e -67R1/o-% <br />G <br />,`r5 <br />f%A2FL Z <br />Generators Phone .�Zoy�r 95 , <br />. ransponer 1 company Name U.S. EPA ID Number <br />Cmo A�� <br />p o ZZ <br />v <br />7. Transporter 2 Company Name U.S. EPA ID Number <br />Ra�lyU, And ire ffAddregs� <br />A/ lni <br />Q/ „ U.S. EPA ID Number <br />AA <br />FaaliyTs•(hone. � �' S 6 K� 10 0 l O �f <br />ga. <br />HM <br />9b. U.S. DOT Description (including Proper Shipping Name, Hazard Class, 10 Number, <br />and Packing Group IN any)) <br />10. Containers <br />11, Total <br />12. Unit <br />13. Waste Codes <br />No. <br />Type <br />Quantity <br />Wt.Nol. <br />W <br />r q�e,nAaa�,�s t/4(Gy n,0S, 3,u,u I. 3 Ei� <br />467 <br />(c/Z <br />�H5S2oL/ P �7 144, 'IJySf/ Lvr y <br />0 <br />w <br />l <br />moo/ <br />Z <br />z. G 5 t gWr erAt6I G <br />r5 Q��ue,Ab)V <br />cy- <br />rL <br />.-7 ,� W3M4, p <br />V2kn ,.03ir <br />3. "557rL I-eA C N o5 S� Ud /?If <br />f 5 <br />cs��b988� , 9 <br />Pr- <br />DF <br />r <br />1C0LVC6jV&LIQ N g t r 7y(7�iVo2 C�4 vyG <br />�S% <br />/nrZ <br />rj05j 9✓ UA 33 �t/ri2�p'LOMCA�'D/ <br />'� <br />IOEf YIf yMt 1C_ Grp i / �( <br />J)F7 <br />pOD/D <br />N <br />14. Special Handling lnsWdans and AddiBonal atlon <br />15. GENERATOR'SIOFFEROR'S CERTIFICATION: I hereby dedare that the contents of this consignment are fully and accurately descdhed above by the proper shipping name, and are dassified, packaged, <br />marked and labeled/placarded, and are in all respects in proper condition for transport according to applicable international and national governmental regulations. N export shipment and I am <br />Exporter, I certify that the contents of this consignment conform to the terms of the anached EPAAcknowledgmenl of Consent. <br />the Primary <br />I certify Out the waste minimization staterrienl identified in 40 CFR 282.27(a) (if I am a large Quantity generator) or (b) if I a s amity generator) is We. <br />Gen or eros Pd yped PZ� 6�e n igna , o/n <br />a ear <br />y <br />A� i ,o lw_/ <br />[� <br />i <br />16. International Shipments <br />❑ Import to U.S. ❑ E U.. Pod of entrylexit: <br />Transporter snature fa exports only): Dale leaving U.S.: <br />Ulu <br />17. Transporter Acknowledgment of Receipt of Materials <br />may. <br />O <br />Tran Prinledrryped Na igna e Month <br />Day yeaF <br />y <br />/ <br />I I <br />Q <br />TdRyped ransporter 2 PnnteName ign re on <br />Ilay YoNr <br />K <br />r— <br />18. Discrepancy <br />fee. Discrepancy Indication Space <br />Quantity ❑ TyDe ❑Residue ❑ PaNal Rejection ❑Full <br />Rejection <br />Manifest Reference Number. <br />18b. Alternate Facility (a Generator) U.S. EPA ID Number <br />J <br />V <br />Q <br />aL <br />Facili s Phone: <br />W <br />a <br />18c. Signature Ifilamate Facility (or Generator) Month <br />Day Year <br />z <br />19. Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste treatment, disposal, and recycling systems) <br />0 <br />1' <br />2. 3. <br />4. <br />Il <br />20. Designated Facility Owner or 0perato : Certification of receipt of hazardous by the manifest cept not m It 1 <br />fmate6alsovered <br />PdntedR Name Signa <br />C <br />M`ofnth <br />if <br />Day Year <br />crm rurr oruo-« knuv. ruo) rrewous eontuns are oosunne. <br />\ I DESIGNATED FACILITY TO DESTINATION STATE (IF REQUIRED) <br />