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L — N <br /> Cl) N N <br /> r <br /> Q Pease pont or type.j Form d O p <br /> designed For use on elite(12-pitch)typewriter.) C <br /> z UNIFORM 11=1RDOUS I Generator to Number Form Approved-QNIG No.2050-0039_ l0 <br /> WASTE MA NI FEST 2.Page for 3-Emergency Response Phone 4,Manifest Tracking Number <br /> {{V[ C <br /> D 5 Genera[o�s Name and A}a,lingpddress JJ n 7 0 <br /> GEneralors Sde Address lii diHereni than mailing addressl � <br /> D o (DCD <br /> zGenerator';Phone.- 3 (D <br /> m 6-Transposer 1 Company Name S <br /> = U.S,EPA 10 Number 11 D <br /> W7.Tfans iter (D <br /> po 2 Cnmpam Name i <br /> U.S.EPA 10 Number Q <br /> g,❑z�[oraled Fa�dity Name and$ile Address O <br /> U.S.EPA It]Number C� <br /> G <br /> Fadllrv's PhonNe: r..t <br /> 9a- 96 U.S.OOT Descnptiw,imel-Aing Proper Shipping Name,Hazard Class.ID Number. 70.Containers <br /> NM and FaAng Group,if enc}', 75.Total Ii UmI 13.Waste Godes 3 <br /> I No Type Quantity Wt Not 3 <br /> O <br /> (D <br /> V) <br /> r <br /> Mr <br /> z 2- <br /> w O <br /> 01 <br /> 00 <br /> Cr) <br /> Pb <br /> N <br /> a <br /> O <br /> as <br /> "4 SGecia!Haadlrng Instructionsto <br /> and Additional Information (D <br /> I <br /> G <br /> (D <br /> cQ <br /> G <br /> 15. GENERA€OR'SfOFFEROR'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. rt <br /> marked and labeled/placarded,and are in all respells in proper condition for transport according to applicable international and national govemmental regulations-If export shipment and I am the Primary O� <br /> Exporter.I aerlify that the contents of this consignment conform to the terrns 01I attached EPAAcknowledgment of Consent C <br /> I cerli that the waste minimization statement identified In 40 CFR 262.27 a 01 am a large quantity <br /> fy (]{ rg q 1y generator}or jh)(ii I am a small quantity generator]is true. <br /> Generators+Offeror 5 PrintedlTyped Name Signature Month Day Year <br /> Q <br /> (D <br /> Ln <br /> J 16.Inlemabonal Shipments Oq <br /> ❑Import 10 U.S. ❑Export from U.S. Porto(entrylexil: O <br /> Transporter signature(far exports only}, Date leaving U.S.- ty <br /> rrt <br /> LU17 Transporter Acknowledgment of Receipt of Materials <br /> rD <br /> Transporter i Printed/Typed Name Signature Month Day Year• Q <br /> a O <br /> 11) Month Day Year <br /> ZZ Transporter 2 PnntedlType-d Name Signature `G <br /> � 1 <br /> W <br /> 18.Discrepancy <br /> 189.Descrepency Indication Space 'Quantity ❑Type ❑Residue ❑Pallial Rejection ❑Full Rejection <br /> Manifest Reference Number: <br /> U.S.EPA ID number <br /> 11 Ailemate Facility(or Gernerai <br /> U <br /> ti Month Day Yea( <br /> 0 re OAR <br /> fW- <br /> Z <br /> 0 calla fpr hazarfts waste(reabnenl,disposal,and recycling systems) p N <br /> 3, 4' O <br /> N Q <br /> aus materiels covered by the mal lied except as <br /> Month ❑ay Y = � <br /> SVgnaWre � � <br /> GENERATOR'S iNMAL COP o) <br /> v W <br /> � rn <br /> (D N <br /> O <br /> W <br /> O <br />