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N��/ <br />_� <br />�Please print or type, (Form desi ned for use on elde 02-dtclti) tymdk-t,)- <br />2 Page I Of 3 Emergency Response Phone 4as ---r777=UNIFORM HAZARDOUS ""a"a"'­"O rWASTE MANIFEST weralars Site Address (W dtfferent than me5, Generatoes Name and Maifing AddressTR <br />� <br />Form nWo -Number -/ <br />" <br />- f <br />! <br />\ � <br />|" / <br />6 Transporteril Compaq Name <br />U,S, EPA 10 Number <br />U.9 EPA 10 Numbilr <br />eall! <br />OF <br />OF 1,44m, <br />9t, U S DOT Descriotw (induding Proper Shipping Name, Hazard Class, ID Numbet 10. Contamers 11, Total 12, Unit 13. =Viaste Codes <br />a. Type Ctuantity &Nol. <br />aid PaOmg Group (J any)) No, <br />Uj <br />0% 0,MVIRCP <br />3, VFDERAL AND STATE REGVLATIOIJS <br />HE <br />15, GENERATORWOFFEROR'S CERTIFICATION: I hereby declare that the coments of tl-oi consignment are fully and aoculatery described above by Me Proper shipping name, and are classfied, packa*, <br />rtiar�ed and labeledtplacardert, and am in all m;pectsm proper condition for transport according to applicable injarnaWnal and national governmental regulason& it expert shipment and I am ma Primary <br />Exporter, I certfy that the tOnlents Of tois onnsignprent conform to the terms of The attached EPAAcknowledgment of Consent <br />i�ejfrrpat the waste rllin,tr;za1b;on 5tatemEn'l—r–A AA eCO 1) uarMy generator) or (b) V I am a small quamitj generator) is true MCF7 —Dayye-I <br />swatunit <br />ell, q <br />yN <br />ManKest Reference Number U,S, EPA ID Number <br />Fec�!'y' Poor, Worn Day Year <br />Or C] Be, Signature of Alternate Facility (or Generator) <br />19 Hazardous Waste Report Management Method Codes (je., codes for hazardoushaste treatment, disposal, and recycling; systems)l <br />'anagament Method <br />EWw, R Codes (,e, -0, <br />to <br />tl�dth Day, Year <br />nature <br />Name <br />