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0 <br />Sq D roct <br />Please print or lime, (Form destrined for use on elite (12-dlchl Ivoewxitenl <br />EPA Form E <br />UNIFORM HAZARDOUS 1. Sa"op"D Numbs" <br />2. Paget of <br />3. E r -m:y Response Film's <br />4.(ManlPost Trackin Nuu7mbe/�r p /�'{ <br />61.4 <br />WASTE MANIFEST <br />QQ O O H 1 DA <br />5. Generators Name and MWIM Address Gen=_r;n:: Site Arouse (tr5lkmnt ben melfrs, address( <br />Generator's Phone: <br />B, Tramporter 1 Company Name U.S. EFA ID Number <br />7, Tmnspmter 2 Company flame U.S. EFA 10 Number <br />8. DesiDna;ed Facility Nam aril SdeAddmse U.S. EPA t I Number <br />Fordo Is Phoca'. <br />go. <br />9b. U.S. DOT Description lreuding Proper Shipping Name, Hazard Sees, ID Number, <br />iC Contalnem <br />11, Total <br />12. Unit <br />No <br />Type <br />HM <br />arM Packing Croup (I any)) <br />Quantity <br />WI.Ncl. <br />13, Waste Codes <br />ad <br />1. <br />w <br />3. <br />4. <br />14. Spatial Ha i&g Instructions andAddtimel Information <br />15. OENERATOR'SIOFFEROR'S CERTIFICATION: I hereby doctors that the embattle of this consignment are fully and accurately described above by Ra proper ddpphg name, and are dessillied, packaged, <br />marked and lebeledrplecerded, and are in al respects Inproper oondi im for emsgodaocordirg to applicable Intamadoneland ndlonal govemmenlal regulations. If export shipment and I am the Primary <br />Exporter, I cedty Ilial tre contends of this consignmenloonlmm M the terms of Bre awed EPAAckwavedgmentof Consent. <br />Iceditythatttewasteminimtratm statement identified in 40 CFR 282.27(a)pf am a large quantity ganerator)or(b)(ill em a small quantity generi is We. <br />Gorsm1cerJ00aot�ntadrryped Name <br />Nk II h l/AMLx <br />18.1memallonal tempmen6 <br />Impnnlo U,S. Ll Expert hem U.S. Poddemrylatet__.,, <br />Trarssporter signature (forexpods only): Date leavitg U.S.; <br />�¢ <br />17. Trsn�oda AcknowledgmsmdReralpl o(Malenals <br />Br I PMIerVT Nome nm Day Yea <br />N <br />aTransporter <br />rate yp ane 5vaimurs, Month Day yaw - <br />13. Dlscrapsncy <br />18a Discrepancy Indication Space ❑ Quanaty ❑Type ❑Residue ❑Partial ReJecaon El Put Re)eclgn <br />Manimet P.ekmnee Number: <br />18b.Ntemate Facsity (or Generator) U.S. EPA ID Wombs, <br />J <br />V <br />LL <br />Fadlllys Phone: <br />W <br />IUQ SignaNm of MI 8mate FaWky for Generator) <br />Motell, Day Year <br />4 <br />S <br />19. Hazadeua Waste Repod Management Method Codes (La. codesfor hazardous waste treatment, disposal, and mcycing syslems) <br />2. ` 3. <br />tick <br />4. <br />20. De iltmaled Facility Owner or Operator. Certification of most of ha:adous materials covered by the sandal except as noted In Item Ise <br />MinldMltypad Name Signa Mmih DAY eon <br />'� <br />USC. ' 7 . , r to I 115 I`3 <br />EPA Form E <br />