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Aq <br /> ,, <br /> Please print or type.(Form designed for use on elite(12-pitch)typewriter.) Form Approved.OMB No.2050-0039 <br /> UNIFORM HAZARDOUS ?Nu8mbe �� ;.Page 1 of 3 Eine ency R�e �nnse Phone 4.Manifest Trackin Number <br /> WASTE MANIFEST j6&e6Vj <br /> (��. 011725430 FLE <br /> 5.C����atajsr��nd Mai Address Generators Site Address(if different than mailing address) <br /> 3. 033S'A00111 We <br /> SWIM,CAM <br /> 2 .234-770© <br /> Generators Phone: <br /> 6, r ns o er 1 ompany amen R� SQ l�ODfa U`�'tllQ N n_ <br /> $ � �i��lt. iT34 <br />' <br /> ion its �a vn ae Mmber <br /> R 435u042 742 <br />' 8.Iters ghate�f g1lity,Name and Site Address U.S.EPA ID Number <br /> lighway ll5 i2 m bs soLth of <br /> 776-6634203 NVT33NIOM <br /> Facility's Phone: <br /> gb.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 13.Wasle Codes <br /> 9a. P l 9 AA 9 11.Total 12.unit <br /> HM, and Packing Group(if any)) No. Type Quantity Wt.Nol. <br /> t. <br /> o <br /> Xon-RWA Nslzalous Waste,Solid (Deb;rb) <br /> DOI o 3D9 <br /> z. 2. <br /> vu <br /> 3. , <br /> 4. <br /> - • V'�Sl 400 Pi4dlfnig Instructions and jZdjVgl&"?n <br /> smWeacy CONTACT.MSF RHODES <br /> 15. GENERATOR'SIOFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully 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 according to applicable international and national governmental regulations.If export shipment and I am the.Primary <br /> Exporter,I certify that the contents of this consignment conform to the terms of the attached EPAAcknowledgment of Consent. J <br /> I certify that the waste minimization statement identified in 40 CFR 262.27(a)(if I am a large quantity generator)or(b)(if I ata small quantity generator)is true. ' <br /> Generatofsl0 eror's PrintedlTyped Name ZjIgn4t re Nlonth Day Year a <br /> —j 16.International Shipments <br /> ❑Import to U.S. ❑Export from U.S. Port of entrylexit: <br /> Transporter signature for exports only): Date leaving U.S.: <br /> ui V.Transporter Acknowledgment of Receipt of Materials <br /> proj6L.Vgdf1•yped Name Signature Manth Day Year <br /> za Transporter 2 Prinledrryped Name Signature yyMonth ay ear <br /> H r Ie e. <br /> I <br /> + 18.Discrepancy <br /> 18a.Discrepancy Indication Space ❑ Quantity ❑Partial Rejection <br /> El El t El Full Rejection <br /> Manifest Reference Number: <br /> 18b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> u- 'Facility's Phone: r <br /> W 18c.Signature of Alternate Facility(or Generator) Month Day Year �'- <br /> a <br /> z <br /> 19.Hazardous Waste Report Management.Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> LU 1. 2. 3. 4. <br /> VV <br /> LI <br /> 20,Designated Facility Owner or operator:Certification of receipt of hazardous materials covered by the manifest exceptiaspted in Item 18a <br /> Pri ed ed a Signat�te Month D y Year <br /> �/ roc <br /> EPA F rn 87 0-22(Rev.305) Previous editions are obsolete. /�" DESIGNATED FACILITY TO GENERATOR TATE(IF REQUIRED) "; <br /> 13007.1602 <br /> '� . . .. <br />