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;A iii <br /> u•. <br /> Please print or type.(Form designed for use on elite(12-pitch)t*ritet.) Form Approved.OMB No.2050-0039 <br /> UNIFORM HAZARDOUS 1.Generator ID Number tar ••,•ift 2.Pag 1 of 3•Em_ se 4.Manffest Traokin Number �+�/��++ <br /> q ... .:,,q--. t1 .. a7Ka7 <br /> Iii <br /> WASTE MANIFEST r) an"',�) <br /> 5.C�erteretor gJ <br /> andr { Generators Site Address(if different than mailing address) <br /> rS rr tr't�if t:iJYt �',.t..t��Rt•:ti <br /> �A11 .'.:� i+, t-.I r)tar.= Cid <br /> a <br /> Generaaloess,Phone: c` `- n17 rP <br /> B.Ttei!-, z.rff0,M,RLrOP" �"she-i-FP4�K ')'ll' S.EPA ID NumberYX(,(!t@(i0,9 .20"3 <br /> i 9P <br /> 7.Transporter 2 Company Name i U.S.EPA ID Number <br /> B.Designated Facility Name and Site Address C,11•j,(rr}M (V••j(r3;r�Ra"':((IRS ry13(10)1 .tp'E;jsj _); .,_,, ^� U.S.EPA ID Number <br /> • d.11�i::d E�C.fll'Y)1 s11:'�f'I I�t.Paf�).i �w"�+•�•.....r� _ . <br /> :.IAN ,:Ft.-?'ail: cc <br /> CAD Ifr�'r'.34943.1,0 <br /> Facibys Phone: <br /> go. 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers: 11.Total 12.Unit 13.Waste Cartes <br /> HM and Packing Group lff any)) No. Type Quantity WtNai. ' <br /> t^ F...,, *NDW W RC 3 Hn-Zi`lRP(:!Us WA ;Tiw <br /> a , • <br /> p ! (C)1L.9 /t ':all; l N'i'>, dLAA <br /> 3 <br /> W �1 <br /> I Z 2. <br /> W d' <br /> j 3 <br /> S <br /> 4. ALT <br /> ENVI ON <br /> nF T ENT <br /> 14.Special Handling Instructions and Additional Information ,gwf 707464,01f r`y' <br /> RUTH As "AGENT...F13RI, BY (Th Tb REi•(UN LICENSED '.-Aja t.tr1RRID.:.11S, OS <br /> 15. GENERATOR'BfOFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by the proper shipping name,and are dassi8ed,padcegadrr <br /> marked and labeledlplacarded,and are in all respects in propbr condition for transport according to applicable intemational and national governmental regulations.If export shipment and I am the Primary <br /> Exporter,I certify that the contents of tNs consignment conform to the terns of the sttactred EPA Acknowledgment of Consent. <br /> I certify that the waste minimization.statement Identified in 40 CFR 26227(a)(If I am a large quan8tyganarator)ot(b)(If.1 am a small quantity generator)Is true. <br /> ator offoror's Prtnted�Typed Name Signatu a Month Day Year <br /> `.ri r , (<'r "1 i 1:, r( t ^; A[.�. <br /> -1 16.International Shipments <br /> F ❑Itnpat to U.S. ❑Export from U.S. Port of entrylexit: <br /> Z Transporter signature(for exports only): Date lesving U.S.: <br /> l W 17.TInsporterAdmoWedgmentof Receipt of Maten'als <br /> I Q Tr�fisp 1 PdntediTyppd Name Signature ( � mh Day Y`gar� <br /> S <br /> TranspoRer2Print Ifyped arae Signature / Month Day Year <br /> rY <br /> 18.Discrepancy. <br /> 18a.Discrepancy Indication Space ❑ Quantity ❑Type ❑Residue ❑Partial Rejection ❑Full Rejection <br /> Manifest Reference Number: <br /> 18b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> Facility's Phone: <br /> i <br /> 18c.Signature of Alternate Facility(or Generator) Day Year <br /> 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> 2. 3. 4. <br /> �. 20.Designated Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manifest exceplp noted In Item i8a <br /> Pdnted T me ) Signature y�.. . ,�, y ..y. ay JYear <br /> T-1-41 I <br /> 4r, <br /> ERP (M fll; yi 6�� uncus edidons are obsolete. DESIGN 'F D f} CILITY TO Gt&IEAATS <br /> S� P <br /> f <br />