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PIG>tandn(nilvae fFnrmdasinned forusenn elite 112-nilchl Utrxawiitef"1 <br />Form Approved. OMD No. 205UO39 <br />:. <br />UNIFORM HAZARDOUS 1. Generator ID Number <br />2. Page 101 <br />- <br />3: Emergency Response Phone <br />4. Manifest Tracking Number <br />O® DAT <br />WASTE MANIFEST ...... <br />-., <br />_ <br />- <br />5. Generators Name and Mailing Address Generators SiteAddreas (if different than maitng address) <br />Generators Phone: " <br />- <br />6. Transporter l Company Name U.S. EPA ID Number <br />-, <br />7,, Transporter Company. Namg., ', _ _. _. _ .. _. ;..:_ - _. _. _ U.S, EPA 10. Numbe[.___. <br />8. Designated Facility Name and Site Address U.S. EPAID Number <br />Fadli sPhme:- <br />So. <br />Do. U.S. DOT Doucripbon(including Proper Shipping Name, Hatard Class, ID Number, _ <br />10. Contalrsrs - <br />11. Total <br />12, Unit <br />13. Waste Codes <br />No. <br />Type <br />HM <br />and Pecking Group (if any)) - <br />.Ouanfity <br />W4,Nd. <br />t <br />..^ <br />r <br />Z <br />2 <br />s <br />r! <br />4, <br />14. Spatial Hopei Instructions and Additional Information <br />15. GENERATOR'SIOFFEROR'SCERTIFICATION: 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 labeledrp ecarded, and are in all respects In proper condleon for transport according to applicable International amid national govemmental regulations. Nexport shipment and I am the Primary <br />Exporter,, II ierlify that the contents of this consignment conform to the tame of the attached EPAAdmowledgmentof Consent <br />I certify thatthe waste minimization statement idanlifed in 40 CFR 262.27(a) (if l am a large quantity generator) or (b)'(ff I am a small quantity generates) N true. <br />GeneraloesrOBe ores Pdnted7fyped Name SlgQaWre it Mcllllr y Year <br />7 <br />F J <br />16. International Shipments <br />❑Import to U.S. ❑Export hom U.S. Port ofenhylexit: <br />Transporter signature (for exports only):. Data leaving U.S: <br />w <br />17. Transpor'erAcknowledgmentofReceiptof Materials <br />Transporter 1 Primed7fyped Name Signature " . Mpnth Day Year <br />Go <br />Transporter Printed/Typed Name Signafu e i Monk) Day 'Year <br />18. Discrepancy` <br />j <br />Ise. Discm,pancy lndlcefirm Space ❑ Ouandy ❑Type El Residue El Partial Rejection ❑Full RejectNn <br />Manifest Reference Number. <br />--"—"--s <br />16b Allemale bauliy (c•Generplor`I �, � +A"_4f 1 {; .'r � 6y,(. (-`. U.S. EPA ID Numher <br />Y0 <br />u <br />Facl ty sPi' <br />w <br />10c Sigrwfure Q[1lWisfle Facility (or Cenemor) : ,• 'l:ie.� - - <br />Month Day : Year <br />Q <br />a <br />y19. <br />HaxaidousN'aste.Report Management Media Cudes(Ie.,codes for hazardous waste treatment, disposal, and recycling systems) <br />4. <br />20 Designated Facility Owner or Operator: Certification of receipt of hazardous materials covered by Cre manifest except as noted in Item 18a <br />Pnnt317ypedNa" Fitrtv r'S = r 'r" -o;r degreWre Moni Day Year <br />VIII <br />EPAI=orfln 87UU-22 (Here. 3,Ub),i'reVlalls ealllons are ob5mem. <br />_ t <br />v <br />DESEGINIATED FACILITY TO GENERATOR:. <br />