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JEJ%4pry <br /> 39 S("PPW Form Approved.OMB No.205M39 <br /> Please print or type.(Form designed for use on elite(12-pitch)typewriter.) 14 2 EeI N <br /> 2.Page I of 1 3.Emergency Response Phone 4.-Man T kin <br /> UNIFORM HAZARDOUS A 0 '1 ("Of��4 fA t"7 8 6 9 M <br /> TE MANIFEST 9 t4 .3 1 '6 3 9, 7 b W1 <br /> 1.Generator ID Number <br /> 5.Generators Name and Mailing Address Generators Site Address(if different than mailing address) <br /> 1,94 4 h H ho W thiv+, <br /> Suvokuss w,1-A 9W41t, 4 -'f <br /> Generators Phone: <br /> 6.-Transporter 1 Company Name U.S.EPA ID Number <br /> IIIA U,0 <br /> 7.Transporter-2Company Name U.S.EPA ID Number <br /> 8.Designated Facility Name and Site Address U.S.EPA ID Number <br /> A <br /> I 0A,fief-rVesfia ROW <br /> 15a n j o s v,I"-'A f'MD 1�2'�c' <br /> Facility's Phone: (40814-41-0962 <br /> 9a. 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers it.Total 12.Unit 13.Waste Codes <br /> HM and Packing Group(if any)) No. Type Quantity Wt.Nol. - <br /> 1. 140"11-W111 R"RA I I&ThR UK'Al W&STV Sally) ft�wv i <br /> 0 C Oft VAIR VR N�A <br /> 2. W A t1A7A(nWV14r1 wrk'411"' 9A'X'j9!4.t Wly <br /> Uj <br /> pf- *I ft TV r <br /> 3. <br /> 4. <br /> 14. Tal Handlin <br /> Instructions and Additional Information <br /> 15. GENERATOR'SlOFFEROR'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. <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 am a small quantity generator)is true. <br /> I Month Year <br /> eratoes/Offerors Printedrryped Name nature Day <br /> F 16.International Shipments El import to U.S. ❑Export from U.S. Port of entry/exit: <br /> K Transporter signature(for exports only): Date leaving U.S.: <br /> UM 17,Transporter Acknowledgment of Receipt of Materials <br /> Month Year <br /> Trans rl Printed ame Signature Ray <br /> f <br /> IL pot <br /> 0 )I L <br /> Month Day Year <br /> ca <br /> Z Transporter 2 Printdd/Typed Name <br /> Signature <br /> < <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space ❑ Quantity El Type EIResidue ❑Partial Rejection ❑Full Rejection <br /> Manifest Reference Number. <br /> 18b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> Facility's Phone: Month Day Year <br /> 18c.SignatureofAlternate Facility(or Generator) <br /> LU <br /> S2 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> 1 A, <br /> Cn ---TTIT 1%I - 2. 3. 4. <br /> LLJ <br /> 20.Designated Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except as noted in Item 1 Be <br /> Pn�ntedrryped Name - Signature Month Day Year <br /> EPA Form 8J00-2ey.3-051 Prevjous editions are obsolete. fm obaw,Wd! 0?1?w"ime the gvk*`#'al#j K Okip GENERATOR'S INITIAL COPY <br /> xv, <br /> AR, �Wl�i 44 <br />