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0 <br />Please print or ". (Form desioned for use on elite (12-oftchl Wwwriter.) <br />C-- A-- — — — —1. <br />�rnr-- u vv -4c knvy. o-vuo ricvwuz truitum did VuW.Mte. DE,;(GNATE1) FACILITY TO GENERATOR <br />UNIFORM HAZARDOUS <br />1, Generator 'D Num;;r <br />Pa5g-eTlof <br />3. Emergency Response Phone 4. <br />Manifest Tracking Number <br />WASTE MANIFEST <br />1 <br />T2, <br />1 <br />JJ K <br />5. Generator's Name and Melling Address Generators Site Address (it different than mailing address) <br />Generator's Phone: <br />6. Transporter I Company Name U -S, EPA ID Number <br />7 Transporter 2 Company Name U.S. EPA ID Number <br />I <br />8 Denlatod Facility Name and Site, Address - <br />U.S. EPA 10 Number <br />Fx&lys Phone: <br />9a. <br />9b, U.S DOT Description (including Proper Shipping Name, Hazard Class, ID Number, <br />10, Containers <br />11. Total <br />12, Unit <br />HM <br />and Packing Group (if any)) <br />Quantity <br />WVW. <br />13. Waste Codes <br />No.0 <br />Type <br />2 <br />0 <br />3. <br />4, <br />14. Special Handling Instructions and Additional Information <br />15. GENERATOR'S/OFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by the proper shipping name. aid are classified, packaged, <br />marked and labeled/placarded, and are in al respects in proper condition for transport according to applicable intemabonal and national governmental r"tions. 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 Acknowledgirnant of Consent, <br />—1 cerfify that the waste minimization statement identified In 40 CFR 262,27(a) (d I am a large quantity generator) or (b) (if I am a small quantity, generator) is true, <br />Gerierator'sKftlor's Printed/Typed Name signature th Day Year <br />16. International Shipments E] Import to U.S. El Exportfrom U.S.Port of entryleyA: <br />Transporter signature (for exports only): Dale Leaving U.S,'. <br />17, Transporter Acknowledgment of Receipt of Maileirials <br />Transporter I Printed;Typed Name Signature Month Day Year <br />0. <br />ca <br />Z <br />-cc <br />Transporter 2 PnnteOTyped N;;; Signature Morith NY Year <br />18, Discrepancy <br />1 Be. Discrepancy Indication Space O.,tity ❑Type El Residue ❑Partial Rejection ❑ Full Rejection <br />Manifest Reference Number <br />18b, Alternate Facility (or Generator) U.S, EPA ID Number <br />LL <br />Facility's Phone: <br />LU <br />18c, Signature of Alternate Facility (or Generator) Month Day Year <br />Z <br />19. Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste treatment, disposal, and recycling systems) <br />GW <br />1 <br />2. <br />T. <br />4. <br />20 Desigli" Facility Owner or Operator. Certification of receipt of hazardous meterials covered by the manifest �e7t� nc Pin�terrillla <br />PrintedrTypedName 5ignature Month Day Yew, <br />�rnr-- u vv -4c knvy. o-vuo ricvwuz truitum did VuW.Mte. DE,;(GNATE1) FACILITY TO GENERATOR <br />