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C— <br /> >D <br /> Pfease pant or type.{Form designed for use an elite(12-pitch) R <br /> Sypewaler I N N <br /> Q UNIFORM FIAZARDOUS 1.Generator ID Number Form Approved OM8 Na.2050.4039 O O C <br /> WA5TE MANIFEST ?.Page 1 01 3,Emergency ea <br /> z 1 Ir�nl 9onse Phone 4.Manifest Tracxing Namoer N <br /> S.Generator Name and Malting Add—, -��M1.�'t'J'U:wJ J J C) <br /> 0 Generators Site Address(Vl Orfe,eM than mailing address) \ O <br /> D <br /> D Genemters Phone (D <br /> z 6,Trensporfer l Campanv Nam? O <br /> M U5 EPA In liumG=.r r.D <br /> "r Transno4er;Gm,an�Na,Tr. D <br /> (n U.S.EPAID Number N <br /> 9, <br /> F <br /> Desiy�ted F,q;dm Name and Siie Atldrass � <br /> U.S.EPA ID H—b� , Q <br /> O <br /> Fatlhh's Phone.- CC <br /> ga. 9b.US-DOT Descnprlon pnduding Proper Shipping Name.Hazard Class,ID Number pCj <br /> HM and Pachino Gros fit eny)r 10,Containers 11.To1e1 12Unit V1 <br /> t3. <br /> 1 NO TypicQuantify ,I Nor. Waste Godes r+(D <br /> c7 rD <br /> In <br /> r-F <br /> I-� <br /> V <br /> tT <br /> I.D <br /> 4 Ol <br /> W <br /> N <br /> 14.Special kandling Instrucfions and Additional Inlormation <br /> O <br /> ID <br /> 15. GENERATOR'S10FFEROR'S CERTIFICATION:I hereb declare that the contents of this const (D <br /> ri y gnmenl are fully and accuraleVy described above by the 4,oPet shipping name,and are classiFed,parMaged, Q <br /> R markad and labeledlplacai and are in all respects in proper condition for transport according to appiirable infemational and national gl:nn, eMal regulations.11 export shipmem and k ann Yne4dmary <br /> Exporter l certdy that the contents of this consignment conform to the terms of the attached EPA Acknowledgment of Consent, <br /> If certify trial the waste mirunrixalion statement identified in 40 CFR 262.27(a)(if I am a large quantity generator)or(b)(it)am a small quantity generator)is Vue. r r <br /> Genera£ers/OReri PrinledlTyped Name Signature Manch gay Meas � <br /> O <br /> C <br /> rrt <br /> J 15.lnlemaGonaf Shipments W <br /> H ❑import to U.S. ❑Export from US. Port of entrylexit <br /> Transporter signature(for exports only), Slake leaving US.'. <br /> Lid17.14ansporerAcknowledgment of Recaipi of Miateaals <br /> In <br /> Transporter 1 PrintedfTyped Name Signature Month Day Year <br /> O � <br /> CIL r+ <br /> Z Transporter 2 PrintedlTyped Name Signature Month Dar ear Q <br /> a <br /> 0 <br /> r O <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space ❑❑ Type YP <br /> e ection❑Residue ❑Partial Rej ❑Fuil Relecfidn <br /> Manifest Reference Number, <br /> U.S EPA ID Number <br /> 186.Alternate Facility(or Generator) <br /> J <br /> U <br /> Phone: <br /> Fadlitys hlonlh Day near <br /> U0 18c.Signature ofAlteri Facility(or Generator <br /> a <br /> a <br /> 19 Hazardous Waste Report Management Method Codes(Te-.codes for hazardous waste treatment,disposal,and ecyc l g systems 4 <br /> O 1' 2. 9 <br /> O n <br /> tor:Cerlificallpn o1 receipt of Hazardous materials covered by the men teat Month Day Year O <br /> 20.Designated Facility Owner or Opera <br /> Printed ed Name <br /> GENERATOR'S iNiT1AL COPY _ <br /> EP 87 Rev. Rfev � � <br /> 0 <br /> v W <br /> � rn <br /> (D N <br /> O <br /> W <br /> O <br />