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Please orinl or lvoe. (Form designed forum on elite (12-Ditchflvoexdter.l <br />Farm AnDowed. OMR No. 20500039 <br />era roan nruu-u (i auo) vrevlous eoiuons are obsolete. GENERATOR'S INITIAL COPY <br />UNIFORM HAZARDOUS 1. Generator ID Number <br />2. Page 1 of <br />3. Emergency Response Phone <br />4. Tracking Number <br />WASTE MANIFEST <br />/M�anifest <br />V O <br />DAT <br />5. Generators Name and Mailing Address Generators Site Address (if differert than mailing address) <br />Genersta's Phone: <br />6. Transpartar 1 Company Name <br />U.S. EPA ID Number <br />7. Transporter 2 Company Name <br />U.S. EPA ID Number <br />8. Designated Facility Name and Site Address <br />U.S. EPA IO Number <br />Fadlfly's Phone. <br />go. <br />9b. U.S. DOT Description (including Proper Shipping Name, Hazard Clan, ID Number, <br />10. Comalnam <br />11. TOUT <br />12. Unit <br />HM <br />and Packing Group in anyp <br />Quantity <br />WWol. <br />10. \Nate Codes <br />No. <br />Type <br />1. <br />a. <br />aO <br />K <br />Z <br />2. <br />W <br />W <br />3. <br />4. _ <br />14, Special Handling Instructions and Additional Information <br />15. GENERATOR'SOFFEROR'S CERTIFICATION: I hereby declare tha� the cements of this consignment are fully and lacurataiy described above by the proper shipping name, and are Gasified, packaged <br />marked aid labeledlplacarded, and are In aI respects In proper coni for transport according to applimble international and national governmental <br />regubdons. If upon shipment and I am the Primary <br />Experter, I tardily that the contents of this consignment conform to the terns of the attached EPA Acknowledgment of Consent. <br />I c rtify that the waste minimization statement dentifiedin 40 CFR 21 (If I am a largequantity generator) or (b) (III am a small quantity generator) <br />b true. <br />GewatoneCiflerers Pnntecinyped Name Signature <br />Month Day Year <br />�j16. <br />z <br />International SNpmen 5 " i <br />❑Import to U.S. ❑Export from U.S. Port of enlrylexiC <br />Transporter signature (for exports ontyl: Dale leaving U.S.: <br />w <br />17. TrersporarAcknowledgment of Real of Materials <br />Transporter 1 PrintedfTyped Name Signature <br />Month Day Year <br />p <br />n <br />N <br />t� <br />y <br />GTransporter <br />2 PrinledRyped Norms Signature <br />Month Day Year <br />K <br />F <br />18. Discrepancy <br />18a. Discrepancy Indication Space ❑ Quanti ry ❑Type ❑Residue <br />❑Partial Refection <br />El Full Rejection <br />Manifest Reference Number: <br />18b. Alternate Facility (or Generator) <br />U.S. EPA ID Number <br />a <br />LL <br />Facility's Phone: <br />18c SignatureofAltemate Feoilityfar Generator) <br />Marty Day Year <br />a <br />z <br />N19. <br />Hazardous waste Report Management Method Codes (i.e., codes for hadartious waste treatment, disposal, and recycling systems) <br />G <br />1. <br />2. 3. <br />4. <br />20. Designated Faolily Owner or Operator: Cerdflcation of rece'pt of hazard materials covered by the manifest except as ndad in Item 1 B <br />Pnnted?yped Name Sicnature <br />Month Day Year <br />era roan nruu-u (i auo) vrevlous eoiuons are obsolete. GENERATOR'S INITIAL COPY <br />