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Plea§e print or type.(Form designed for use on elite(12-pitch)typewriter.) Form Approved.OMB No.2050-0039TrackingNumber <br /> 1.Generator 10 Number 2.PagEt 1 of 3.Eme no ani0-b <br /> Re <br /> HAZARDOUS UNIFORM HAZAR ELE <br /> WASTE MANIFEST <br /> 5.Generator's Name and Mailing Address Generator's Site Address(if different than mailing address) <br /> A; <br /> Generators Phone: U.S.EPA ID Number <br /> 6.Tra <br /> rter 1'Company Name <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> d Site Address rf";, U.S;EPA Ip Number <br /> 8.Designated Facility Name an ci r" I'e- I P.- <br /> -5 Q if j S L.. <br /> IF- <br /> Facility's Phone: <br /> 9a. . 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit 13.Waste Codes <br /> HM and Packing Group(if any)) No. Type Quantity Wtivol. <br /> -4- <br /> CK <br /> 0 A J <br /> Z 2. <br /> UJI <br /> 3. <br /> 4. <br /> 4Y <br /> 14.Special Handling Instructions and Additional Information <br /> .-I C: <br /> 15. GENERATOR!SIOFFEROWS CERTIFICATION:I I 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 labelediplacarded,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 EPA Acknowledgment 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 /> Month Day ?ear <br /> s nr <br /> X <br /> -j 16.Int-e—mational Shipments 0 Import to U.S. ❑Export from U.S. Port of entrylexit: <br /> Transporter signature for exports onl : Date leavinq U.S.: <br /> WMont17.Transporter Acknowledgment of Receipt of Materials <br /> Transpgriel I Pdntdrr, ignature <br /> h Day Year <br /> S <br /> 0 <br /> Z Tran o er 2 PrIntedfryped Name Signature <br /> rt Month Day Year <br /> < I A; <br /> 18,Discrepancy <br /> 18a.Discrepancy Indication Space El Quantity El Type El Residue E:]P.,fal Rejection FFull Rejection <br /> •Manifest Reference Number. <br /> 18b.AJtemate Facility(or Generator) U.S.EPA ID Number <br /> Facility's Phone: Month Day Year <br /> W18c.Signature of Alternate Facility(or Generator) <br /> CD 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> UJI <br /> U) 2. --T 4. <br /> 20.Designated Facility Owner or Operator.Certification of receipt of hazardous materials covered by the manifest except as riptedin Item I Be <br /> PrintedT:e Signature I-'/. N I I .'*) .-- -11 0 ay ar <br /> Name., 7:;, <br /> editions,•�'.�•� t�f 4✓� 'L �.:! '�iF� � f`" . 1 ri ,f--� ?`� `r^'E ,-„',�__,__.�.,+�"._ �,,�n,l C .' � <br /> a '15so DESIGNATED FACILITY TO GENERATOR <br /> re o6g@ie�te.� <br /> EPA Form'F 2(Rev.3-jq�) Previous <br />