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<br />Please Pnrit or type. (Form designed for use on elite (12 -pitch) typewriter)
<br />EPA Fwrni (Kea. 3-U,-) Kevious eoworis are oDwiate.
<br />i ED f'!1k'1:11LA t Y I Q Otake NATUK'
<br />UNIFORM HAZARDOUS
<br />ID
<br />Response Phone
<br />41-ga6st I TrackiU Number
<br />WASTE MANIFEST
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<br />5 Gerarg"or'sName and Ma'trg Address Genera!Vs Site AW*eSs (if different than, mai'mg address)
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<br />51M 8 A WK
<br />81m,"Mai, (A
<br />Generator's Phone: (MMUMA
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<br />1. vlsperter ! Company KFe— US EPA IrDNkx7bv
<br />Ij S EPAID Numtcf
<br />Delgrated US EPAID
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<br />61313 E &1 4 Ow w
<br />A%knon, hug-/, 97
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<br />9b, U.8 DOT 9e5c'not""Incs,ldn Propef Shipping Name, Hazan! Cass. I') Nwnber,
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<br />12 Unit
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<br />13 Y"aste Codes
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<br />1._'«l.* ial Handing instwaivrs and Add.lurzl Diformatxxn
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<br />15 GENERATOR'SiOFFEROR'S CERTIFICATION: 1 fterf,,tvleVare That the con,.Cts c;s consignment are fully and aw-jr�itely desvibeciacove by the proper shppi-griarre, and are ria ,pckaqed,
<br />warked and lawed!olatardc-d, and are in l respects in praper cisndition for transport a x ding to applicable internatory shat ,,e. and I 8T�the PrInnary
<br />Expdrils f-caltifir It* the coverts of his coragnrnent conlonn to bie terms of the atfa&isd EPA AcMowedgrrient of Consent
<br />hw",fyt!"'al: tlwasle CFR 2U 27�p) ifl an, a targe il.jaltny ,ere aro, Dr1i;
<br />Ge Ctrs erors Prin, yped ma morio Do, Ya
<br />Shipments
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<br />Tra,.spoL srqrature jfar ex oris onlyi: j S,:
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<br />�7, Tra, of Receipt of Materials
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<br />2 PnnteJ7yjed Name� Moott, Da" Year
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<br />Mardes, Ref, once N��ncer.
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<br />186. krernate Facility (cr Generator) S EPA ID Number
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<br />B,. Sig o, a, L,, re, n I Ate ma.e Fac I. -T Ge,,,erator` !Jnnv's Day Yes-,
<br />IS Ha2ardoustiVaStC Rapr',.1,10-.gerueol MeCW Codes codes to; hazardojswaste tfealirent, disposal. and riscyc4nq systems)
<br />2.
<br />21, aa.a r t Onvner or ot naceipt qpiazarps materiiis covered by ihs rranifest except as ro!ed in ftea:,0a
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<br />F Sigralure
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<br />EPA Fwrni (Kea. 3-U,-) Kevious eoworis are oDwiate.
<br />i ED f'!1k'1:11LA t Y I Q Otake NATUK'
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