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Please print or Noe. fF'orm deslaned for use on elite f12-nitchIrtvoewdtec1 Fnrro Annmved. OMAN. 706n-nn3g <br />AFM i vigil Of Uv-�gl"e'• cool riewUUb eUIUUIO die owUiem. DESIGNATED FACILITY TO GENERATOR <br />UNIFORM HAZARDOUS 1. Generator ID Number - <br />2. Page 1 of <br />3. Emergency Response Phone <br />4. Ma hnI TTracId Number <br />WASTE MANIFEST <br />, <br />OO ,J O 0 ID ',..1 DAT <br />y� <br />V } <br />5. Generators Name and Mailing Address Generator's Site Address (if different than mailing address) <br />Generators Phone: <br />6. Transporter 1 Company Name U.S. EPA ID Number <br />7. Transporter 2 Company Name U.S. EPA ID Number <br />r�fll rca �� � �l�L - • <br />8. Designated Designated Facility Name and SlteAddress U.S. EPA ID Number <br />11 <br />t L 1 l� <br />Facility's Phone: ,,. „� ; • i , <br />ga, <br />lit. U.S. DOT Descnptlon (including Proper Shipping Name, Hazard Class, ID Number, <br />10, Contalners <br />11. Total <br />12. Unit <br />'HM <br />and Packing Group (ifany)j <br />Quantity <br />WiNaI. <br />13.Wasm Codes <br />No. <br />Type <br />¢ <br />1" NINI Khri+ rhr jllRbRi1 Alt, I[ '2'! I d i rrAE e1A Li"I 210 1 N': P, I <br />z <br />2. <br />w <br />f9 <br />3. <br />4. <br />14, Special Handling Insbudlons and Additional Information <br />15. GENERATOR'SIOFFEROR'SCERTIRGATION: 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 lebaledlplacerded, and are In all respects in proper condition for transport according to applicable international and national governmental regulations. Ifexpod shipment and I am the Primary <br />Exporter, I cerilly, that the contents of this consignment conform to the terms of the attached EPAAcknowledgmenlaf Confused. <br />I certify that the wash minimization statement identified In 40 CFR 262.27(a) (if I am a large quangty germartdr) or (b) (if] am a small quantity generator) Is We, <br />Gerreratorsl0lferors Printed?yped Name Signature Month Day Year <br />J <br />F <br />16. Interna8onel Shipmentsv <br />ElImport to U.S. ❑ Expodfrom U.S. Pont of enlrylexib <br />Transporter signalum (for exports only): Date leaving U.S.: <br />w <br />17. TranspoderAcknoNledgment of Receipt of Materials <br />OTransporter <br />1 PrintedrTyped Name Signature Month Day Year <br />C <br />Tted4yp0 Nama renspdder2 Frin- to, Month Day Year <br />it fil �i I i ✓' j -d ' ,•, /I ZIP, / <br />_ <br />B. Discrepancy <br />T1 <br />18e. Discrepancy Indication Space ❑ Clantlry ❑Type ❑Residue ❑ Parts[ Rejection El Full Rejection <br />Manifest Reference Number: <br />18b.Altemale Feclllty(or Generator)1,, �1r •-,i f .I's if ,/)I, if(C ,L ': r.. (nzl 1, J, U.S, EPA ID Number <br />U <br />.-L-.•�tx jl rt t f,t 1ti .Y <br />uQ. <br />Facility'a phone: <br />18c.Sgnature ofAltemata Fadlity(or Generator) <br />Month Day Year <br />w19. <br />Hazardous Waste Report Management Method Codes (Le., codes for hazardous waste hea ment, disposal, and recycling systems) <br />o <br />L <br />2. _ 3. <br />4. <br />20. Designated Pacllitf Owner or Operator, Certification of receipt of hazardous materials covered by the manifest except as wed in Item 18a <br />11I <br />P nedrryped Name Signature Month Day Year <br />AFM i vigil Of Uv-�gl"e'• cool riewUUb eUIUUIO die owUiem. DESIGNATED FACILITY TO GENERATOR <br />