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" ':j <br />e <br />Please Drint or tvoe. (Form designed for use nn Alite 119_nitnh1 hrnalerritar t <br />UNIFORM HAZARDOUS <br />t e r,,DNp- <br />P!! <br />3. Emergency Response Phone <br />Manifest Tracking Number <br />WASTE MANIFEST <br />`: ..h . <br />14. <br />Ge <br />00 r: , 5 f <br />5 Gene(ator',9Nar a and Mailing Address Generator's Site Address (if different than mailing address) <br />f� l�. di�i,i V¢ ),l'i _ <br />a <br />Generator's Phone: c f` Alk12 �'41{ c1 <br />6. Tranks�Ort r 1 Company Name d U.' <br />6 kib ar lea t '0l "s v9 d"a &JAt, <br />�...$c 'it k:re�'.V`��� JB 4`y$ SI �X ea 5� Pa60r§x <br />aIt16,"wail ma''ei' <br />7. Transporter 2 Company Name U.S. EPA ID Number <br />8. Designated Facility Name and Site Address U.S. EPA ID Nu ber <br />fatst�-'V !@=a,9 �}t'fs[i� frd(:_ `1 sv <br />—tit 1�. 1). <br />u t'E bi.:lc 2Pp& .,l�;#, <br />Facility's Phone: <br />ga <br />9b. U.S. DOT Description (including Proper Shipping Name, Hazard Class, ID Number, <br />10. Containers11. <br />Total <br />12Unit <br />HM <br />and Packing Group (if any)) <br />Quantity <br />. <br />Wt.Nol. <br />13. Waste Codes <br />No. <br />Type <br />0 <br />1�.. TYf 9f. :r �5D711� P'i 1r IF.u3i4 tii4e'F/_d <br />A <br />F (f1,.o� A <br />Z <br />2. <br />1 <br />(j vi <br />3. <br />4. <br />14. Special Handling Instructions and Additional Information <br />'t8d,et mg g,'$ t'y,, 141"aa:g0". *f § <br />15. GENERATOR'SIOFFEROR'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, <br />marked and labeled/placarded, and are in all respects in proper condition for transport according to applicable 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 EPA Acknowledgment of Consent. <br />I certify that the waste minimization statement identified in 40 CFR 262.27(a) (if I am a large quantity generator) or (b) (if I am a small quantity generator) is true. <br />Generator's/Offeror's Printed/Typed Name Signature r` r; Month Day Year <br />d l <br />X <br />JW. 1''I d� , 7{"- 'i1 `dl� k' 8",+al �'�f �4 �Ga s' �.�-,..mer <br />J <br />ZE] <br />16. International Shipments` ••-•- <br />Importto U.S. ❑ Export from U.S. ,Pott of entry/exit <br />— <br />Transporter signature (for exports only): Date leaving U.S.: <br />Ll <br />17. Transporter Acknowledgment of Receipt of Materials <br />Transporter 1 Printed/Typed Name Si natu.e <br />9,„r " Month Day Year <br />, _ <br />QTransporter <br />2 Printed/Typed Name Signature Month Day Year <br />e- <br />18. Discrepancy <br />18a. Discrepancy Indication Space <br />Quantity El Type El Residue ❑ Pallial Rejection 1 El Full Rejection <br />Manifest Reference Number: <br />18b. Alternate Facility (or Generator) <br />U.S. EPA ID Number <br />J <br />V <br />Facility's Phone: <br />C3 <br />18c. Signature of Alternate Facility (or Generator) <br />Q <br />Month Day Year <br />Z <br />N19. <br />Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste treatment, disposal, and recycling systems) <br />® <br />1. <br />2. <br />3. <br />4 <br />it; b'-(9 <br />20. Designated Facility Owner or Operator: Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a Xf If <br />Pri tedfryped Name Si natur Month Day Year <br />L <br />