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Form Approved,oved OMB No.2050-0039 <br /> Please print or type.(Farm designed far use on elite.(12 pitch)typewrite_r.) _ r f -� ' 4.Mariitest Trackin Number <br /> UNIFORM HAZARQDt]S 1 Generator VD Number r+ r+f7 f {] C JZPagpiof :Emergency'Re,S_nse{Pflne p?�p s'�7- r��qg¢ 5_�j p`y�; �� <br /> CAD9024,7,178"4,7, lr::l i] - '3 .r'y:f t V"` �],.7 r r- - _eJ`al d�!f V W <br /> WASTE MANIFEST <br /> Generators Site Address(if different than mailing address) <br /> 5.Generator's Name and Mailing Address <br /> r l f 3 "t.l" iia.Llt <br /> {(i'it�13E <br /> T91, ..6779 9S206 <br /> Generator's Phone: - ' ' 5' C Y <br /> 6.TranspVq,,Q Com y'Name r _ U_S.EPA ID Number <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> 8.Designated Facility Name and Site Address l.= U.S.EPA ID Number <br /> Facility's Phone- <br /> ga 9b.U.S.DOT Descriplion(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 W1.1vol. <br /> 1.�.(; l,i iy�•Y; i <br /> 4TS WASHER SCIL01' 0N <br /> z 2. <br /> w <br /> C7 <br /> 3. <br /> 4. <br /> 14.Special Handling Instructions and Additional Information j�r� `il:�t c Ffb_. ;: <br /> HR E(1Lri%LNa~_Y SYS.;. -800-468-1?60 (SX TF1 <br /> r r OEM TO P�TPIN i,AT�#`L,F.." -6,1.1 L. <br /> 15. GENERATOR'SIOFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurateiy described above by the proper shipping name,and are classified,packaged, <br /> marked and labeledlplacarded.and are in all respects in proper condition for transport according to app%able international and national 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. <br /> I terrify that the waste minimization statement identified in 40 CFR 262.27(a)('d I am a large quantity generator)or(b)(if I am a small quantity generator)is true. <br /> Generator' Offerors Priniedfryped Name Signature Month Day Year <br /> -j 16,IhternaUonal Shipmenls : <br /> F-- ❑Import to U.S. ❑Export from US. Pert of enlrylexit � <br /> Transporter signature(for exports only): hate leaving U.S.: <br /> 17.Transporter AcknoW edgmen t of Receipt of Materials <br /> LLf <br /> 0� Transporter 1 PrintedlTyped Name Signature Month Day Year <br /> O �L /J �.^ 01 JoelIan <br /> QTransporter PnntedfTy*Name Signature { Month Day Year <br /> 1115F <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space ❑ Quantity ❑Type ❑Residue ❑Partial Rejection ❑Full Rejection <br /> Manifest Reference Number. <br /> r 18b.Alternate Facility{or Generator) U.S_EPA ID Number <br /> i <br /> ;.r <br /> FaciNy's Phone: <br /> W 18c.Signature of Alternate Facility(or Generator) Month Day Year <br /> a <br /> z <br /> 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> LLIi 2. 3. 4. <br /> 20 Desgnatad Facility Owner or Operator.Certificaftn of recelpt or hazardous malerials Covered by the manifest except as noted in Item 18a <br /> PnntedlTyped ame Signature��yyy fMonth Day Year <br /> r f 5 <br /> EFA Form 8 00.2 (Rev-3-05) Previous editions are obsojete. DESIGNATED PACILITY TO GENERATOR <br />