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L Please pnrrt w lype.jForrn <br /> D PVi HAZARD desr <br /> g71 <br /> UNIFORM ned!°ruse on elite 12-pitch)lypewmec} <br /> Q IFEST <br /> WASTE M OUS Generator ID Number O NO N <br /> AN2.flags t rn a E Fnrm Approved OMB No.2050-9939 0 C <br /> z `Generator's Name and M merg"-^ry Response Ahone 4.Manne6l Tracking Numyer F N G <br /> aron9 Address J J K � O <br /> Generator's Sita Atldress pf difl O <br /> D erenl Ihan mailing atldrattil <br /> N <br /> Generator's Phone- (D <br /> D 6.Transporter I ~' <br /> z Company Name 0 <br /> U.S.EPA Ip Numher CD <br /> fll 7 Transposer 2 Company Name � D <br /> = rCu < <br /> U 5 EPA Ip Number N tD <br /> 8 Designated Facilrh Name and Site Address <br /> U.S.EPA ID Numtr?r 0 <br /> O <br /> C <br /> Facilitys Phone: N <br /> 9a. 9b.If.S DOT Description tincluding Proper Shipping Name,Hazard Class.ID Number, <br /> HM and Packing Group(if anyl) 10.Containers rn <br /> 11 To1aV 12 Unll r--F <br /> No TYPe Quantity Wt Nor 13.Waste Codes (D <br /> o 3 <br /> w 0 <br /> z <br /> w �p <br /> C7 N <br /> r-I• <br /> O <br /> N <br /> W <br /> v <br /> O <br /> 4. O <br /> Cr) <br /> r. <br /> 74.Special Handling lnslructions and Additional fnformation ' <br /> N <br /> N <br /> G <br /> fD <br /> 15. GENERATOR'SlOFFEROR'S CERTIFICATION:I hereby declare that the contents of this consignment are fully antl accurately descnbed above by the proper shipping name,arld are dassified.packaged, <br /> marked and lai7eledlpiararded,and are in all respects in proper condition for transport according to applicahle internal and natioral governmental regulations_If export shipment and I am the Primary <br /> Exporter,I certify that the contents of this consignment conform to the terms of the attached EPAAcknowledgment of Consent r••� <br /> I certify that the waste minimization statement identified in 40 CFR 262.27(a if I am a large uan6 <br /> 1 f rg q ty generator)or(b)lift am a small quantity generator)is true. 0 <br /> Ganeratorsl0ffem(s PnntedlTyped Name Signatufe Month Day Year r�.t <br /> N <br /> 16.Intemalional Shipments F1 <br /> ❑impart to U.S. ❑Export from U.S. Portof entrylexih (D <br /> ? 7ranspoder signature(For exports only): rn <br /> Date leaving U.S.: • <br /> 17.TransporterAcknowledgmenl of Receipt of MatenaIs all0 <br /> O edr <br /> Transporter}PrinlFyped Name Signature Month Day Year <br /> on !Z <br /> on <br /> Q Transporter 2 PnnledlTyped Name Signature Month Day Year 0 <br /> H -0 <br /> 18 Discrepancy <br /> 18a.Discrepancy Indication Space <br /> ❑ Quantity LJ Tp- ❑Residue ❑Partial Rejection full Relectron <br /> Mandest Reference Number'. <br /> H 19h.Aftemate Fac,14y(or Gwterill U.S.EPA ID Number <br /> .:J <br /> U <br /> 0 Facldya Phow Month Day Year <br /> ry lik.SipnallofAlt&T"Facill(or Generator, <br /> a <br /> z <br /> a19 Haz wdl1,W Report Managerrle d Metflod Cudes G 0.codas Jar hazardous waste treatment.disposal,and recycling systems) <br /> C t 2 9, a 0 0 <br /> (Q n <br /> � O <br /> v Q <br /> 3i.Dwpslul►fscih Crlrw or lapratar CarYAratlor!of ma pl of h ueldaue materials covered by tlse manifest except se noted in Item t8a g Dar Year <br /> 2 �k <br /> 1fa�wystataNk GENERATOR'S INITIAL COPY <br /> O <br /> v w <br /> � rn <br /> (D N <br /> Cf) <br /> O <br /> W <br /> O <br />