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PlpiqA nrint or tvnp fFnrm rfp.qinnad fnr use on Mile 1124iitchl hinAwritarl <br />NJ "T <br />Fnrrn Annmvpd, OMR Nn 2n9&W3A <br />EPA Form $7" (Rev 1W Prevm WWare obsolete. <br />DESIGNATED FACLMMV <br />�AE <br />o <br />UNIFORM HAZARDOUS 1. Generator ID NumbdUPV—,V&t,- 4- W MW r 2. age 1 of <br />.04 * <br />-r- <br />3. Emergency Response Phone <br />4.robar <br />G B F <br />WASTE MANIFEST 4ILt; r r-jf <br />1301233118 <br />5. Generator's Name and Mailing Address Generator's Site Address (I different than mailing address) <br />Generator's Phone: Art, 6a, cpysw <br />6. Transporter I Company Nam U.S. EPA ID Number <br />b iT-Q.L I VIP 42qS <br />. a-julia IQ) L z ofc., <br />7. Transporter 2 Company Name U.S. EPA ID Number <br />8. esigna me and Site Address U.S. EPA ID Number <br />lwifYVls/91— V7 <br />F.dfr*sone: <br />ga. <br />9b. U.S. DOT Description (including Proper Shipping Name, Hazard Class, ID Number, <br />10. Containers <br />11. Total <br />12. Unit <br />13. WWa Codes <br />No. <br />Type <br />HM <br />and Packing Group (if any)) <br />Quantity <br />".Not. <br />#0 Y7 <br />ul <br />2. <br />3. <br />. ................ <br />4. <br />14. Special Handing Instructions and Additional Information VV 6"C- <br />24 4(f& <br />r r10Q. '714 isi, i <br />ilt NR T r --'j C <br />15. GENERATOR'S/0 CE (CATION: I hereby declare that ft content" this consignment are fully and accurately described above by the proper shipping name, ard are classified, packaged. <br />marked and la=, an in all respects in proper condition fort according to applicable international and national governmental regulations. If export shipment and I am the Primary <br />Exporter, I certify that the contents ofl"&ignment conform to the tup" the attached EPAArknovAedgment of Consent. <br />t <br />I certify that the waste minimization staiemiir�in40 �C 1(a) (if I am a large quantity generator) or (b) (91 am a small quantity generator) is true. <br />�&toeslOfferoes Printed/Typed Name Signature Monlh Day Year <br />Stevq_-Te 1/0 1/ 7 JC <br />WK e M 0-1 <br />-1 <br />IL.- <br />16. Intemational Shipments <br />11 Import t. U.S. El Export from U.S. Pool of entrylexlL <br />Transporter signature (for exports only): Date leaving U.S.: <br />17. Transpoqef Acknowledgment of Receipt of Materials <br />TW—porter I PrintedfTyped Name Signature Manth Day Yew <br />0 <br />r 1 <br />Z <br />Transporter 2 PrintedfTyped Name Signature W -r* Day <br />18. Discrepancy <br />18& Discrepancy Indication Space El Quantity 7❑Type El Residue ❑Partial Rejection <br />M&wW Reference Number. <br />18b. Alternate Facility (or Generator) U.S.+PA ID Number <br />Facility's Phow <br />LU <br />18c. Signature of Alternate Facility (or Generator) <br />subav&ft oft* <br />CO2 <br />19. Hazardous Vftste Report Management Method Codes (i.e., codes for <br />LU <br />1. <br />2. <br />4. <br />Designaled Facility orgm �i -±Mftern---- <br />Owner Certification of receipt of hHa <br />J!" Materials cm—: <br />Fldntwffyped <br />174y <br />EPA Form $7" (Rev 1W Prevm WWare obsolete. <br />DESIGNATED FACLMMV <br />�AE <br />o <br />