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0 <br />Please rxint or tune, tForm designed for use on elite (1241dpl tvnewriterI <br />9 f A ---A MAD \L, oncn noon <br />C rrenws eenam3 are ocswere. OFSIGNATED FACILITY TOfIESTINATION STATE (IF REQUIRED) <br />UNIFORM HAZARDOUS <br />1. Geneabr ID Nunbar <br />2. Page 1 of <br />3. Emergency Response Phone 4Manifest <br />dohfumber <br />WASTE MANIFEST <br />C'AL OW20M <br />1 <br />1-�► 7%,t'� <br />0080' <br />5. erator's Name and affing Address GsneraWr Site Addrm (ii dfferefct Mhan mdiiing ed ss) <br />8wall; Y <br />i <br />Generatcr's Ptx <br />Transporter 1 � � 11MU:S. EPA B) NumberAdo <br />1. Tror6pondr 2 Company Name U:S. EPA 10 Number <br />8.Oesianaled Fac6ly Name and Site Address U.S. EPA ID Number <br />Us L4d=N" <br />'1 Non a q owy i�%7:i � <br />"�'�" <br />Beany <br />• <br />Factht 's Phone' <br />9e. <br />9b• U.S. DOT Description (Including Proper Shipping Name, Hazard Class, ID Number, <br />10. Contatners11. <br />Total <br />12. Unit <br />HM <br />and Pack <br />Packing GrarP (9 any)) <br />Quantity <br />13. Waste Codes <br />WtNol. <br />No. <br />Type <br />CRA Ha>cardoms Waste <br />0M <br />P <br />1 u� <br />I <br />Lu <br />ex <br />XT v <br />..j <br />4 i <br />X <br />ons <br />3�t� <br />U111111117 OW4 <br />P !_ <br />4. <br />Nbu **SO-%%CPjj wvt%ro 4ja-Rvit. (CAV r.Al-^ <br />A' e <br />`v ( <br />i4. SpedaB Na xt pg Ir>sinkt enc and 1Wditiariat Inf "Zion <br />PRIed QrWmt *011001 <br />Aln1816i4tISM 8UW-Q2��xti5;ar MEW OMMMMI <br />T ISWI1l"6tel- 'moi 13t :?ate 6 G <br />15. GBNERATOR'SIOFFEROR'S CERTIFICATION: i hereby declare that the contents of this consignment are fully and accurately described above by the proper stripping name, and are classified, pad®ged, <br />merited and Iabeled/ptacarded, end are In all respects in proper condition for transport according to oppikable International and renal governmental regulations. If export shipment and I am the Primary <br />Exporter, I certify that the contents of this consignment coofomp to the terms of the alladW EPAAckno*Iedgr l rd. <br />I menti sle minimization slalemem Identified in 40 CFR 282.27(a) ('d I am a Marge quantity genera or (b) of t4i a nor emlur) is true. <br />Generator roes niedl re Year <br />�<' 1 IIA �S <br />j <br />l — <br />16. International ants <br />import to U.S. E] Export from U.S. Port of entryfexik <br />= <br />Transportiar signature (for exports only): Date leaving U S <br />17. TransporterAdgwvAedgment of Receipt of Maw <br />Transporter 1 PrkntedfTyped Name ear <br />R <br />N <br />C -4v:>,` &1 0 1 I& 115- <br />sTransporter <br />Transporter2 PrintaCyped Name nature Month Day Year <br />18, Discrepancy <br />18a. Discrepancy indication Space El a entity ❑ Type ❑ Residue ❑ Partial R*odon ❑ Ful Rejection <br />Manifest ReWence Number. <br />18b.ARemata Facially(or Generabr) U.S. EPA ID Number <br />V <br />Q <br />LL <br />Facl!M Plane: <br />19c. Sigialwo of AHerrnate Facility (or Generator) Month Day Year <br />a <br />z <br />US19. <br />liatardars Waste Report Management Method Codes (l.e., us for hezardowaste treatment, disposal, and recyrArg ysterns) <br />3. <br />C <br />1. <br />T <br />?)21— <br />4. <br />20. Designated Facility Owner or Operator: CertikcaBon of receipt of hazardous materials covered by Bre manifest except as noted in Item 18a <br />Preried(Typed <br />� , A <br />Signet Ifo <br />C rrenws eenam3 are ocswere. OFSIGNATED FACILITY TOfIESTINATION STATE (IF REQUIRED) <br />