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0 <br />Please print or mw (Form des' ned for use 1 -pitch) y writer. Form Approved.OMB Flo. 2050-09 <br />UNIFORM RDQUS <br />t or 1D Nu r 2. Page 1 of 3, En° y R naw P 4. Man Tracking Number <br />JJK <br />WASTE MANIFEST �.`, � • < �� , <br />5, GenaraW. Name and Mairing Address Generator s Site Address (if ' nt than ntarAng s) <br />Generator's 6S. EPA1D Number <br />8. Transprrriar 1 Caanpa>nB Name <br />U.S, EPA 16 Number <br />7. Transporter 2 Company Name <br />Number <br />Facdibp and Sita ss U S. tq <br />FaGllty'9 Pfiorre; <br />9b. U.S. DOT Description (instuding Proper Shipping Nand, Hazard Glass, ID Number, 10, Containers 11. Total 12, Unit 13, Waste Codes <br />HM and Packing Group (if any)) <br />No. Type Ouantity WtWill. <br />r <br />e <br />s <br />tt.l <br />2. <br />LU <br />(Ti fT 6€ JTR M}j Sid�t" <br />EAENTM <br />n>,,', <br />3. , ; i 5 <br />MEMO� � <br />ri. r ('t'r .Tti9S FACILiT orf°, ani ty `t Ct ARY <br />4 7, r1 <br />UAC F4FD. OUR EPA NuMRFR 1 .A C U13� M <br />14 S Handling In Fats and 9 <br />15. GENERATOR'SlgFFERpR'5 CERTIFICATION : l hereby re that the contents of this consignment are fully and accurately described above by the shipping nam, and are cla ' <br />marked and €abeledtpiacarded, and are in all cts in proper condition for transport ding to appy ant®mat ona(and national gaeemmantal regulations. If export shipment and i am Primary <br />Exporter. l certify that the contents of this consignment conform to the terms of the attached EPAAcknowtedgment of Consent, <br />I certify that the waste minimization statement identified in 40 CFR 262.27(a) (if t am a targe quantity generator) or (b) (if t am a small quantity generator) a true, <br />Month Day Year <br />enerator'siOfferor's Printeddfyped Name Signaoire r k <br />G <br />16. tritemationai Shipments �} <br />F El import to U.S. Export from U.S Port le a n} U.S 6 <br />Transporter signature (for exports only): gate leaving U.S, <br />17. Transporter Ackricivoledgment of Receipt of Matenats <br />Transporter 1 Prsrttedir Nam Signature Manor Day Year <br />011 <br />0 <br />W 1 t , _ <br />QTransporter 2 PRmtedir yped Nam SignatureMonth gay Year <br />18 Discrepancy <br />1 sa Discrepancy Indication Space El oue" Type El Residue i t Partial Rejection Q Full Rejection <br />iftsst Ref <br />1#bASternatdFa itylot Generator) <br />U.S. EPAtDNµmber <br />'.t <br />LL Facility's e. Month <br />I6c, Signature of Alternate Facility (or rotor) gay Year <br />2 <br />19. Hazardous Waste Report Management Method Codes (ia- cafes for hazardous waste treatment, disposal, and recycling systems) <br />14, <br />20. Designated Facility i }honer or Operator: Certification of receipt of hazardous materials covered by the manifest except as noted in Rem 18a <br />yC Signature Month Day Year <br />EPA Form t374o 22 (Rev. 3*) Previous edrtidn`s are uttsotete. i NAT t it � E Ft Et <br />