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13 <br />EFTMUT. =-, <br />Form Awroved. umb No. 2050-0039 <br />QFA t-orm 6tl!1�-ZZ fRev. �rfb) Previous "+ ti=c are obsolete. TRANSPORTER'S COPY <br />UNIFORM r 10 Number <br />2. Page I of <br />---- <br />3. Emergency Response Phone <br />4.Manifest Imcicing Number <br />WASTE M <br />-,C� <br />I 0112M'34 <br />JJK <br />5. Generators Name and Mailing Address Gefterator's S49 Address (if dftrent hw mailing address) <br />gr-KLAG Iles <br />'SIZI .Zjrkjff"-i <br />�TOLKTC���, �'-- <br />Gonerstoes Phone: <br />6, Transporter I Company Rams <br />U.S. EPA 0 Number <br />(rt'xjt J-Zw�f 4. <br />1 �rust t,ni 4o'r,oi, <br />7. Transporter 2 Company Name <br />U.S. EPA ID Number <br />8. Designated Facility Name and Site Addless <br />U.S. EPA ID Number <br />LA. <br />Facility's Phone: 'X&M3-A-Vtl <br />9b. U.S. DOT Description (including Proper Stripping Nam, Hazard Class, (D <br />10. <br />11, Total <br />12, Unit <br />13. Waste Codes <br />No. <br />Type <br />and Pecking Group ((if aryl) <br />Quantity <br />MjvLb <br />2. "LAZOPOCUS VVASCL" LOW %u «ei, <br />r <br />30 <br />3. <br />4, <br />14. Special Harding Instrucom and Additional inbmathn <br />15. GENERATOR' S/CffEROR'S CERTIFICAMN: 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 labsladozcaare in an respects in proper condiflon for transport according to applicable internatonal and national governmentaf regulations. If export shipment and I am the Pnmry <br />Exporter, I ce" #0 the contents of this wisigement conform to the terms of the attached EPA AdmoMedgment of Consent. <br />),certify that the waste rnmirrizabon statement iderdtited in 40 CFR 26227(a) (K I am a large quantity generator) or (b) (9 1 -w a sman quantity _qRDVzid0T) <br />is true. <br />GaperatoeslOfferces PnnName s rha <br />Month may Year <br />-j <br />1- <br />16. International Shonems <br />0 import to U.S. n from UT Port of entryfeA: -7 <br />3 <br />Transporter Kmture (for exports only): Date leavirg U.S.: <br />A <br />= <br />U J! <br />17. Transporter AckraNiedgmerd of Rewo of hilsomals <br />- <br />0 <br />Transpoo qpai*eq�e S° nature <br />yelift <br />as <br />Transporter 2 Pdn0Fy—pdFZM7 Signature <br />Month Day Year <br />18. Discrepancy <br />18x. Discrepancy Indication Space Quantity Type Read. <br />Partial RjWin <br />❑Full R*d.n <br />Manifest Reference Number <br />18b. Altemate Facility (or Generator) <br />U.S. EPA ID Number <br />14- <br />Facillys Phone; <br />1 Be. Signature of Alternate Facinty (or Generator) <br />Month Day Year <br />19. Hazardous to geport Management Method Codes (i.e., codes for hazardous to treatment, disposal, and recycling systems) <br />LU <br />1 <br />2 , <br />_1 <br />13 <br />20, Desqdated Facility Owner or Operator. Cerdcation of r9go of xiscmered by the manifest except as fted m tem 18a <br />A <br />Printed/Typed Name 77 Signature <br />Ut-h Day year <br />QFA t-orm 6tl!1�-ZZ fRev. �rfb) Previous "+ ti=c are obsolete. TRANSPORTER'S COPY <br />