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4'2 <br /> Please pmt or type.(Form designed for use on elite(12-pitch)typwbf.) Form Approved.OMB No.2050-0039 <br /> UNIFORM HAZARDOUS 1 1.Generator ID Number 2.Page 1 of 3,Emergency Response Phone 4. n Tracking Number <br /> C'. <br /> WASTE MANIFEST @ 83 <br /> 20543 -SKS- <br /> 5.Generator's Name and Mailing Address Generator's Site Address(ddffcmntthan mailing address) <br /> HOW RD <br /> 15 <br /> Generator's Phone: <br /> 6.Transporter 1 Company NameU.S.EPA ID Number <br /> ,.41[41"y-'X,-'FAi -7�STEMR' IMC, <br /> 7.Transporter 2 Company Name U.S.EPA 10 Number <br /> 8.Designated Facility Name and Sfts AWress SDS ET SYSTEMS, INC, L�Mql ID Number <br /> r-f)CPFP E; r( ROAD <br /> -rX <br /> Facility's Phone: <br /> ga 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers11.Tow 12 Unit 13,Wastat Codes <br /> HM and Packing Group No. Type Quantity. WUVol. <br /> P'i-Piili BILE LIQUE <br /> 0A 11 r9t <br /> yyt;'in,J!, FLUORIPS) <br /> LU <br /> S. <br /> 4. <br /> 14.Special Handling Instructions and Additional Information <br /> 1. M.— <br /> .1 A 131#t 2"a <br /> a4 riR EME GEN't"', ii";G;KMAM #341M <br /> I: "'4' 41 4 1,D j"-':-. i S S'F il JEW FL a 0 R 1 5'f 4 10-1,11 &1471-A 1 A A I-A 7A q A!i:;q Cl <br /> 15. G----ERATOR'SlOFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are Qiy and accurately described above by the proper shipping name,and are classified,packaged, <br /> marked and labeled/placarded,and are in all respects in proper condition for transport acmaling to applicable international and national governmental regulations.If export shipment and I am the Primary <br /> Exporter,I certify that to contents of this consignment conform to the terns of the attached EPAAcknowledgment of Consent. <br /> I certify that the waste minimization statement identified In 40 CFR 262.27(a)(rf I am a large quantity generator)or(b)(if I am a small quantity generato is true, <br /> toev'Offeror's PrinteXyped Name SigqaWue Month Day Year <br /> c�j 16.International Shipments <br /> 1— El Import to U.S. ❑&Port from U.S. Port ofentry/exit' <br /> Transporter signature(for exports only): Date leaving U.S.: <br /> UW 17.Transporter Acknowledgment of Receipt of Materials <br /> pa r 1 Pmted[Typed Marne Signsture,,4' Month Day Year <br /> ix <br /> 0 <br /> rn <br /> Transporter 2 PrintediTyped Now Signature Month Day Year <br /> 18.Discrepancy <br /> laa.Discrepancy Indication Space <br /> El Quantity ❑Type ❑Residue ❑Partial Rejection El Full Rejed.n <br /> Manifest Reference Number. <br /> 18b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> L4L Facjlitys None: <br /> 18c.Signature of Alternate Facility(or Generator) Month Day Year <br /> 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> 1. i 1 2. 7 1 4. <br /> 20.Designated Facility Owner or Operator.Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a <br /> Td-Z—d1TypedN3me gnature Month Day Year <br /> EPA FjDp-8jDq-RZ CR <br /> Ry.305) Preyious editions are obsolete. GENERATOR'S INITIAL COPY <br />