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r— Annr6.ati nMR Nn 2054-4439 <br />Please <br />print or type. (Form designed for use on eine ti4-pacn) typew-U, I <br />Generator ID Number <br />UNIFORM HAZARDOUS <br />-- <br />2. Page 1 of <br />3. Emergency Response Phone <br />Manifest Tfuum umber <br />0 1. 31 JJK <br />WASTE MANIFEST <br />- A." <br />g- <br />—Gentratoes Name arta Mailing Address <br />Generators Site Address (it different than mailing Address) <br />Gerrcratoes Phone:U.S. <br />EPA ID Number <br />6. Trarisporter I Company Name" <br />U.S EPA ID Number <br />7. Transporter 2 Company Name <br />8. D�,rgnatzd Fa lity Name and Site Address <br />VS, EPA ID Number <br />PrIone <br />9, U.S-DO Description (including Proper Shipping Nam. Hazard Class ID Number, <br />10 con 11 Total 12 unit 13, Waste Codes <br />9a <br />Ht,1 and PackjN- Grour,,Y any)) <br />No� Quantity VitAlol. - <br />0,� <br />'y <br />0 <br />A A, <br />z <br />LU <br />UJ <br />A <br />A <br />4 <br />74 Special Handling lnslructions and Additional Information <br />15. GENERATOR'SICFFEROR'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 />international national governmental regulations, if export shipment and I am the Primary <br />rriarkeu and labeled-?P"ZcardedL and are in all respects in proper condition for transport according to applicable and <br />� tents of thi consignment conlomi to the terms of the an EPA A nt of Consent <br />Exporte" 1 ceiiifi Oat E con ached cknowledgme is rue <br />40 CFR 262,27(a) (if I am a large quantity generator) or (b) to I am, a smali quantity generator) <br />ori, statement Identified in <br />-Month Day Year, <br />Gerieratoes,OfferVs Printer-1,Typed Name <br />signah" 1� <br />2 i <br />N- Al <br />PFIE6, <br />iriternational sbipments lmpoq to U.S' Export from U S Pod ofentryeA. <br />13 <br />1 <br />Transporter signature (for exportsonly);Date <br />leaving U.S.: <br />Vansporte', I Pdntedqyped Nepe <br />4 <br />.8 Dscrepancy <br />18a- Discrepancy indication space ouaritity, L]Type❑Residue <br />Manifest Reff <br />18b: Alternate Facility for Generator) <br />Faililltv's phone <br />J&, Sg.)atureo(Allemate Faciiityfor ijenerinor) <br />Wu <br />Z <br />19, Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste treatment disposal, and recycling systems) <br />WG <br />2. <br />20 De$�natad Facilq uxner or Operator: Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a <br />D�� <br />finnJOITyped Nam S"twe '- ��,X <br />r Jz- <br />! <br />EPA Ford 8103122 (Rev. 3-05) Previous ed4ioKare obsoteW <br />F7 Partial Rejection 0 Full Rejection <br />FAMIlTY TO GE- NEFtXrOA <br />