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•ry�/ ���a. CCK 61 61, ,,�,,, f ���/ [/( ! '" - • • , . ,� ioe <br /> ' ch ewriter. Form Approved . OMB No. 2050.0039 <br /> Please pnn, or type. (Form designed for use on elite (12-plt ) typ ) <br /> UNIFORM HAZARDOUS <br /> III Generator ID Number 2. Page of 3. Emergen sponse Phone 4. Manifest7racking Number <br /> W4STE MANIFEST : r?j 2 ,�- y _that : �, . 00950790 fl FLE <br /> eneratots Name and Ma8ingAddress Generators Site Address (it different than mailing address). <br /> ucc. tj0C .+40C /vAC 61Nsr1T'u777o10v row) <br /> SS 0 'R A C>4. MAI .' S V�t"L r� Nfi �} t} L) <br /> Genft eP n: � 53 � � c) - .< y y <br /> 6. Transporter I Company Name U.S. EPA ID Number <br /> . 10tH '! A I t6oU A S n I Z=4 Z2 n ft% e / <br /> 7. Tran porter 2 Company Name U. . EPA ID N m6er <br /> S. Designated Facility Name and Site Address U.S. EPA ID Number <br /> AAS'rCJCf/L CLC l <br /> ci ity's Phone: i9 ZSs5 3 G 5 ,. IWI Notn <br /> 9a. gb. U.S. DOT Description (including Proper Shipping Name, Hazard Class, ID Number, 10, Containers 11 . Total 12. Unit 13. Waste Codes <br /> HM and Packing Group (if any)) No. Type Quantity Wt1Vol. <br /> ' NA. IIIA Ia, 4 s4ro51 q , pt, 7= V. <br /> 0 <br /> IQ P I <br /> z 2. • <br /> 777' Ll OF 9 <br /> 3*N0N Q C&A NA) '?,4 /Zp0u S 7•E C / etc t IIS <br /> CwArV? 13ASCO atmiulwSfoNS� <br /> w <br /> 't•NON 12c. IZA 1JAV11fJ0" ,S wAsr WOL 10 <br /> ofL / 72 � t) P1 t 1 0 67 a <br /> Special Handling Instructions and Additional Information <br /> 1SE5rOS • . � , sta � 3b - SCJ l) °"lex C2G5 <br /> �QA) S )S6sroS- �# PnpfCIOtl3G - sc , a� y � 55� 1 <br /> GJ L+,/RTbY( f3/4 SC's /3Ar/vr,.4/7 ,Q GJ Ho �f 3 J X / <br /> r . t '11 - // Orr l 1 - LLJ = sr, l <br /> 15' GENERATOR'SIOFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are tiny and mrately d scribed above by the proper shipping name; arid are classified, packaged, <br /> marked and labeledlpiacarded, arii are in all respects in proper condition for transport according to applicable international and national governmental regulations. If export shipment and I sin IhePrimary, <br /> Exporter, I certify that that contenticif this consignment conform to the terms of the attached EPA Ackrowled ent of Consent, <br /> 1 certify that the waste minimization statement identified in 40 CFR 26217(a) (if I am a large quantity generor (b) (if i am a small quantity generator),is true. <br /> Gene esl0 enols Printed(Typed Name ure : r on a e <br /> mi 16. International Shipments El ImPQ ,rt to U.S. ❑ Export from U.S. . Portof entry/exiC. i ^' <br /> Transporter siature (for exports only): Date leavina U.S.: ' <br /> W 17, TranspoderAcknowiedgmentof Receipt of Materials <br /> Transporter 1 PrintedRyped Name Signature nth Day Year <br /> C J J �� nalGre , an pay r <br /> M <br /> Z Transporter2 PrintedrTyped Name g <br /> F <br /> 18. Discrepancy <br /> 18a: Oisuepahcy Indication Spate El Quantity ❑ Type ❑ Residue ❑ Partial Rejection El Full Rejection . <br /> Manifest Reference Number: <br /> �. 18b. Alternate Facility (or Generator) U.S. EPA ID Number <br /> V • <br /> w <br /> Facilitys Phone: <br /> 18c. Signature ofAltemate Facility (or Generator) Month Day Year <br /> Q L <br /> Hazardous Waste Report Management Method Codas p.a., as for hazardous waste treatment disposal, and recycling systems) <br /> 2. 3. "' SEP 9 1 '1. U16 <br /> 20. Designated Facility Owner or Operator. Certificetion of receipt of hazardous materials covered by the manifest except as noted in Item 18a ' Gd n <br /> PrintedfTyped Name signature ,�jonlh Day Year <br /> EPA:Form.87.00.22 (Rev..3t05) Previous editions are otisolete. DESIGNATED FACILITY TO GENERATOR STATE (IF REQUIRED) <br />