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0 <br />PW=*tortm. (Form desioned for use on elite (124tch) Woewriter t <br />Gran Ann —A r Ac? Ern ancn Mon <br />n rViui w w -cc iRt:V. rue) nevn�u5 CuirWnS are ODSOrele. ,� �, r O , { <br />9 Generator ID Number <br />UNIFORM HAZARDOUSng <br />2. Page 1 of <br />3. Emergency Response PhoneMon"Trackt <br />Number <br />WASTE MANIFESTFLE <br />5. Generator`s Name and Mailing Address Generators ' Address (if different than marling address) <br />, <br />Generator's Phone <br />6. Transporter 1 Company Name U.S. EPA ID Number <br />v <br />d .S w .. kcs 2E• <br />7. Transporter 2 Company Name U.S. EPA ID Number <br />B. Designated Facility Name and Site Address U.S. EPA ID Number <br />S <br />Facility's Phone: <br />ga. <br />9b. U.S. DOT Description (including Paper Shipping Name, Hazard Class, ID Number; <br />10. Containers <br />11. Total <br />12. Unit <br />HM <br />and Packing Gaup (if any)) <br />Quantity <br />WtNol. <br />13. Waste Codes <br />Na. <br />Type <br />2. <br />t <br />LU <br />i <br />3. <br />4, <br />14. Special Handling Instructions and Additional Information <br />15. GENERATOR'SIOFFEROR'S CERTIFICATION: 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 labeledlplacarded, and are in all respects in proper condition for transport acourdirg to applicable international and national governmental regulations. If export shipment and I am the Primary <br />F.xporter, I certify,that the contents of this consignment conform to the terms of the attached EPAAcknowfqdgmeAtcf Consent. <br />n ...... , <br />I certify that the waste minim` tion statement identified in 40 CFR 262.27(a) (if I am a targe quantity generator) or (b) (d I am a small quantify geperator) is,true. <br />enerata st s Fqnw I ypgName SignatureMonth Day Yaw <br /># ~ <br />-' <br />F <br />16. International Shipments. <br />ElImportto U.S. ❑ Export from U.S. Part <br />of entrytexfl:_<. <br />Trans iter sictriature for exports ): Date leaving U.S.: <br />W <br />17. Transporter ent of Receipt of Materials <br />Transporter 1 Printed/Typed Name Signature Month <br />p� <br />Day ear <br />) . <br />Q <br />Transporter 2 Printedrryped Name Signature an ay Year <br />18. Discrepancy <br />18a. Discrepancy indication Space <br />Quantity ❑Type ❑Residue ❑Partial Rejection El Full Rejection <br />Manifest Reference Number: <br />18b. Alternate Facility (or Generator) U.S. EPA ID Number <br />43 <br />'s <br />u- <br />LLJ18c. <br />Fadli Phone: <br />Signature of Alternate Facility (or Generator) Month Day Year <br />13. Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste treatment, disposal, and recycling systems) <br />p <br />1. <br />2. <br />3, <br />4. <br />20. Designated Facility Owner or Operator. Certification of receipt of hazardous materials covered by the man'dest except as noted in Item 1 Be <br />txrirntedtfppect NameSignature Month Day Yaar <br />n rViui w w -cc iRt:V. rue) nevn�u5 CuirWnS are ODSOrele. ,� �, r O , { <br />