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- n ICT..., an- nn..r! fn. ee nn el le 11'1 r'Irhl 1 rrw ,lcrl Enron Annmvad. OMG No: 205MO39 EPAForn 87UU-;U(Nef 3-Ub)?revlous Win= are Dbsobote: ,- - DE5IGNAfED n1li ilY IV 4itNt_ti&sVi; UNIFORMHAWDOUS 1.GwrwatorlD Number ... .. 2. Page t of 3. Emergency Response Phone 4. ,Nanifesf Tracking Number. OO. ®AT WASTE MANIFEST - 5. Generators Name and Mailing Address Generalofs Side Address (if different than mailing address) Generators Phone: - - 6. Transpader i Company Name U.S. EPA ID Number ... Z.'Transppder2 Company.NamE.;. _: _. _ .. _. .,_,_ _. _. _ _- . _ _.._U S_EPAID Number I. Designated Facillly Name and Site Address - U.S. EPA ID Number - Facilltys Phone' ge So. U.S. DOT Doarsiption(10Clcding Proper Shipping Name, Hazard Class, ID Number, 10. Coofainers 11. Total' 12. Unit 13. Waste Codes - No. Type HM and Packing Group (if any)) .Quantity Wt.Nd. z 2 w — f r 4. 14.,Speerial Handling Instructions and Additional Information 15. GENERATOR'SIOFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described shove by the propershipping Tama, and are classified, packaged, marked and labeled/placarded, and are in all respects in proper condition for transport according to applicable iMemalional and natural governmental regulations. If expand shipment and I am Bre Primary Expader,Icerflfy that the contents of this consignment conform to the terms of the attached EPAAcknowledgment of Consent I certify that the waste minimization statement identified in 40 CFR 262.27(a)(if l am a largo quay ly generator) or (b) (I I am a small quantity generator)is true. - Ggn9ratoeslOfferafs PnntedrTyped Name Sig share Br t MoPW Day Year r' 7f�4+• F- 16. International Shipments ❑Impon to U.S. ❑Export from U.S. Pat of antry1wit: z Transporter signature(for exports only):, Dale leaving U.S.: - w 17.7ransponerAcknaxledgment of Rei of Matwas - - Transporter 1 Primodlfyped Nama Signature Mpn1h Oay Year a L Ili A M Tor sportor 2 PrintedlTyped Name SlgnatVc - Month Day Yeft Discrepancy' r - -, j18. iBar. Discreparcy Indication Space ❑adentiry ❑Type❑ Reddue PaNal Rejection Full Rejectg Manifest Reference Number 1Bb Agq !3GHy Ipr.Generptor) r 4 r;. c a .� },( , �. t �, �^ + .(„ (_' US EPAIO Number r LL Factldys Pho'pe: >' �; w 18a IgrtaWxg yf,Aygr,,,te Facility(or Genem,or) fl...p% ....... 7 MmN OaY ' Year zz y19. Hazardous Waste. Report Management Which Codes (i.e., codes fee hazardous waste treatment disposal, am boarding systems) -T. L -. 2. - r . 4. 20 Designated FactlRy Owner or Operator Cerhficadon of receipt of haeardous materials covered by the manliest exceplas noted In Item 18a PnntedUyped Name Slgnpture Month.Day Year i ` t EPAForn 87UU-;U(Nef 3-Ub)?revlous Win= are Dbsobote: ,- - DE5IGNAfED n1li ilY IV 4itNt_ti&sVi;