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j <br />olneee nanf m wm 19n.n dncinnn,t fne um nn clan 119 -nit h1 hrnawriforl <br />Form Approved. OMB No. 2050-0039 <br />Number <br />EPA corm 8f00 -2z (Rev. 3-Ub) Hremeus editions are obsolete. DESIGNATED FACILITYTO GENERATOR <br />UNIFORM HAZARDOUS 1. Generator ID Number <br />2. Page 1 of <br />3. Emergency Response Phone <br />4. Manifest Tracking <br />DAT <br />100"1'038562 <br />WASTE MANIFEST i. - <br />5. Generatots Name and Mailing Address Generalists Site Address (if different than mailing address) <br />A ^ <br />. <br />Generator's Phone: , <br />6. Transporter 1 Company Name <br />U.S. EPA ID Number <br />7. Transporter 2 Company Name <br />U.S. EPA ID Number <br />, <br />B. Designated Facility Name and Site Address--, - <br />U.S. EPA ID Number <br />- -- <br />Fadlity's Phone: <br />- <br />98, <br />9b. U.S. DOT Description (Including Proper Shipping Name, Hazard Class, ID Number, <br />10. Containem <br />11. Total <br />12. Unit <br />13. Waste Codes <br />No. <br />Type <br />HM <br />and Packing Group Illfany)) <br />Quantity <br />VAJVal. <br />1. <br />W <br />2. <br />9 <br />3. <br />4. <br />- <br />�, <br />TT <br />122—, <br />14, Special Handling Instructions and Additional Information <br />15. GENERATOR'SIOFFEROR'S CERTIFICATION: I hereby declare that the contents of this coimentam fully and accurately described shove 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 international and national governmental <br />regulations: If export shipment and i <br />am the Primary <br />Exporter, I cantly that the contents of this copsignmentconform to the terms of the attached EPA Acknowledgment of Consent. <br />- <br />I'cerihi M the waste minimization statement Identified in 40 CFR 26227(a) (If I am a large quantity generator) or (b) (NI am a small quantity generator) Is Ime. <br />Generatots/Ofierofs PrinledlTyped Name - Signature - <br />Month Day Year <br />� <br />F <br />16. international Shipments e> - <br />❑Imperttc U.S. ❑Export from U.S. Podofendylexlt: <br />K <br />Transporter signature(for exports only): Date leaving U.S.: <br />17. TranspalerAcknowledgment of Receipt of Materials <br />Tia rter i Printedliyped N, attie Slgtmture. <br />1 I�Vjll } <br />Month Day Year <br />��<<} 1' Ix _ <br />? fr it"� I <br />AVY'���VI 1, n^Irl <br />r- �,n i- <br />G <br />Trznspoder2PrintedQyped Name j/ �'^ Signature - - - <br />'i= Month Day Tear <br />ro i iate <br />11II <br />18. Discrepancy _ <br />18a. Discrepancy indication Space ❑ Quantity perr2fwi#or 1«M1t�p',Cj <br />❑ Partial Relecllon <br />El Full Rejection <br />�t <br />the waste this yen <br />Manifest ReferenceNumher: <br />16h. Alternate Facility (or Generator) <br />U.S. EPA ID Number <br />J <br />LL <br />Facility's Phone: _, j f D' <br />W <br />ISo. Signature of Alternate Facility (or Generator) <br />Month Day Year <br />a <br />z <br />h19. <br />Hazardous Waste Report Management Method Codes (i.e. codes for hazardous waste treatment, disposal, and recycling systems) <br />0 <br />7. <br />2. 3. - <br />4. <br />20, Designated Facility Owner or Operator: Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a <br />- <br />Printedfryped Name Signature <br />Month Day Year <br />EPA corm 8f00 -2z (Rev. 3-Ub) Hremeus editions are obsolete. DESIGNATED FACILITYTO GENERATOR <br />