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Please print or".(Form designed for use on elite(12-pitch)typewriter.) Form Approved,OMB No.2450.0039 <br /> UNIFORM HAZARDOUS t.Generator ID Number «y 2.Page 1 of 3.Emergpency Response Phona 4.Manifost Tracking Number <br /> WASTE MANIFEST L p(�,� 17` ® (�*51-017,61 018640247 JJK <br /> 5,Generator's Name and Mailing Address Ganamtoes SbAddmss(diAerent than mail eddress) w� <br /> LfOVIVE' AL SERV!GC 1z'Erty"Me. /N� e M <br /> Generatofs Phone: 7—o <br /> 5.7ransporter 1 Company Name U.S.EPA ID Number <br /> � SSP k7. LL e- &0 01, 1.572- <br /> 7.Transporter 2 Company Name U,S.EPA ID Number <br /> 8,Designated F elity and S to U.S.EPA ID Number <br /> ry <br /> Faciihy's Phone; �® <br /> ga. 9b.U.S.DOT Description(including Proper Shipping Name,Heard Class,ID Number, 10.Containers 1i.Total 12.Unit 13.Waste Codas <br /> HM and Packing Group(if any)) No. Type Quantify WLA(d. <br /> 0 1>m ZOO <br /> t w® 6i it } <br /> 2' ,a#- c RA <br /> (q bso k be o,j) 2W ILO <br /> 3. 11 *S JS <br /> eA <br /> 331 <br /> 4 >_ <br /> ,�. <br /> 14.Wei Handling lnstrucGons'andAdffftraT <br /> 2 rte• '/� � / A&56F . <br /> I3 <br /> 1.24 <br /> r t"' 8 a <br /> 15. GENERATOR'Stt)FFEROR'S CERTIFiCATtON:1 '" dedaie * of fids bbr s itant we fusty end accurately described above by the proper shippatg name,and are classtfiad,packaged, <br /> marked and labeladfoacarded,and are in all respects in paper condift for transport socor ft to applicable international and national govemmentul regulations.If export shipment and I am the Primary <br /> Exporter,I car*that the contents of this consignment conform to the tam of the attached EPAAdwMadgmerd of Consent <br /> I ear*that the waste minimization statement identified 1n 44 CFR 282.27(a)(d I am a large quantity generator)or(b)(if f am a small quantity generator)is bua. <br /> GeneratoesfOfifemes PnnMrryped Name Signature Month Day Year <br /> T` ,WY==== __ ! <br /> r iB.UttemaBonal Shipments ❑Exportfmm U.S. Pod of ant yf.,* <br /> t� El import to U.S. <br /> Tisignature(for exports only): Date leaving U.S.; <br /> 17._TwVoderAdwMe#wt of Receipt of Materials <br /> Ix Transporw1 ypad Signature Month Ray r <br /> Tans —ffivwyypof Signature'L, Month Day Year <br /> 18.Discrepancy <br /> 16a.Discrepancy Indication Spero .. a ❑Type ❑Residue ❑Penial Refection ❑Full R*d. <br /> Manifest Reference Number: <br /> s AFernate Facility((,r Genorator) U,S.EPA ID Number <br /> Phorw <br /> of Alternate Facility(or Generator) Month Day Year <br /> Report Management Method Codes(Le.,codes for hazardous i sta treabient disposal,and mcydng systems) <br /> 2. 3. 4. <br /> x� <br /> Ope�ato Certificat wr of recast of trrtuus materials covered by the manumit except as noted in Item 16a <br /> gnaiure Month Day Year <br /> editions are obsolideDESIGNATED FACILITY TO DESTINATION STATE(IF REQUIRED) <br />