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Form Approved dMB No , <br /> Please prmt�Ir'1A% orm designed for use on elite(12 pitch)typewr ter) ' 2 Pap 1 of 3 Emergency Re.spo tse 'hone,,. 4.manifest Tracking Number <br /> 1:Generatorlb Number <br /> a: <br /> tJMFORMHA7JxR(30US _016— ��� <br /> WASTE MA IFEST <br /> Generatdes Site Address(if different than.mailing address) <br /> 5 Generatcts Na a pd Mailrn <br /> Afid�gs z „ <br /> .x3.. <br /> wq z <br /> Generators Phane U S EPf}ID Nufnbr s <br /> 6,Transporter 1 Company Name <br /> � s <br /> U S EPA ID Number <br /> (Transporter 2 Company tJa e -2,e <br /> ! <br /> 7 <br /> U.S.EPA IQ;Nu.mber <br /> 8 De srg dated Flatill. (Name and SEte Address <br /> PacilitysPhone' w��'Ar { Y r - <br /> � a r r•: <br /> 10 Containers, ,,11,{Tata! t 12�ntt 13`Waste Codes <br /> 9a.: -gb U S DOT'bescrfpiion ncludmg Proper Shipping Name Hazard"Class;fD Numberi: Nv Type Quantdy Wi Nol <br /> HM and Packing Group(if any)) a <br /> O <br /> Lid <br /> W <br /> cg <br /> 3 <br /> 4: r . ,: <br /> t <br /> 14 Special Handling Instructrans and Adddioilai Iniormatibn " <br /> r ICATtON;`I fiereb declare that the canfants of this consignment are fully and accurately described above liy Yne proper shipping Hartle and t and ssrnf YYdie Pnry d <br /> 15 GENERATOR:SlOFFERQRSCER7tP y <br /> piarked"arid IaEietedlplacatdad and are;rn alt respects in proper oonditibn for transport according to applicable International and national gvvernmeritai regulations.If export sh p <br /> Exporter I cei#ffy that the-contents of this consignment conform to the terms of the attached EPAAcknowiedgment of Consent.. <br /> I certdy thattl a waste minimizatfonstatement idetitfed"in"40 CFR 262.27(a)(if I am a.large quantity.generator}or(b),('!f!am.a small quantity generator)is true. M1}nth Day Year: <br /> Generator slOfferor`s Pnhtedfrypetl Name Signature d . <br /> 16 ltitemationa!Shipments" ❑Export from U.S. Port of entryfextt ' <br /> ❑..lrriport to U.S: Date leaving U.S,: <br /> Transporter signature(for exports only). . i <br /> 17,Transporter Ackhowledgment of Receipt of Materials <br /> Signature.. � •6T � � MOP0 Day Year <br /> z. <br /> Tmnsport�er�l°Pri.tedlTyp d Ja 7 F: , .rp " <br /> Month Day . Year <br /> Q Transporter 2 Pnr tadfryped Nam r S�gnatrrre s t; r* # <br /> 7 <br /> 18 t3iscrepancy <br /> 18a-.Discrepancy IRdication Space Type ❑Residue El Pariial:ftejection Full Rejection. <br /> 0 Quantity <br /> Manrfesi Reference Number: <br /> U.S.EPAIDNumb . <br /> er <br /> 186:Altemata.Fac lity(or Generator). <br /> rat Facliily s Phone: Month Day .'Year <br /> 15:Slgnafi re.of Alternate Facility(or Generator) <br /> LU <br /> 19.Hazardous Ui!aste Report Managemerit-Meihod.Codes(t.e.,codes for hazardous waste:treafinent disposal and recycling systems) <br /> UJ 1 N. <br /> 3. 4 <br /> [] ' <br /> 20:I]esignated.Facility Owner or Operator Certification bf receiptof hazardous materials.covered by.1he manifest except as noted in Item 18a' Month Day Year <br /> PrintedlTyped Name <br /> Signature <br /> P�auiniicariifinncareClh5(Tlete. ' RANSPORTER'S COPY <br />