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Plaase mint nr tvna. (Form daninnad forum nn AIM 110.nifnhl funawrlfnr 1 4 <br />" - i DESIGNATED FACILITY,TO GENERATOR. <br />HAZARDOUS <br />,tt.Generator ID Number <br />2. Page 1 of <br />3.,Emergency Response Phone <br />4. anifest Tracking NumberASTE <br />MANIFEST <br />FUNIFORM5. <br />'JieratQ <br />s Nramme andel Mailiingddress `� t Generator's site Address (If different than mailing address) <br />�y 7 e'np 'Forms4wrY't r <br />M a X19 r <br />`i 2co) I"i 95 roa,c/ � v <br />Genera orsho < i. <br />6. Transporter 1 Company Name 1g (t r,.� U.S. EPAq ID Number <br />Y�»;aA ,p <br />7. Transporter 2 Company Name U.S. EPA ID Number <br />B. Designated Facility Name and Site Address U.S. EPA ID Number <br />EVEW-IfFFN 011x;, NC, <br />NEWA CA 04660 MM�(;',�FAQ <br />Facilil es Phone: <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 />HM <br />and Packing Group (if any)) <br />Quantity <br />Wt.Nol. <br />13. Waste Codes <br />No. <br />Type <br />Aya9in V'JA . ff f , LiQUID <br />0011 <br />" <br />/UJ <br />V <br />3. <br />4. <br />14. Special Handling Instructions and Additional Information <br />PROFL _ <br />O' ERG4," 171 WEAR PROTECTIVE CLO -MING Sa ldFtt9 Order .ir 41-'0 IV 2, 3 W -� 74.• <br />15. GENERATOR'SIOFFEROR'S CERTIFICATION:.t hereby dec are thatthe contents of_ this consignment are fully and accurately described above by the proper shipping oarrre, and are classiffed,;packaged, <br />marked and labeled/placarded, and are in all respects in proper condition for transport arcading 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 tl* 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 />Gener r's/Qfferors PrintedfTyped Name Signature Month Day Year <br />-t <br />� <br />16. International Shipments <br />pments , <br />❑ import to U.S. <br />P ❑ Export from U.S. Port ofent�y/exit: <br />z <br />Transporter signature (for exports only): Date leaving U.S.: <br />UX <br />17. TransporterAcknovAedgment of Receipt of Materials <br />CL <br />Transporter 1 Printed/Typed Name � Signature) Month Day Year <br />�" ` t <br />At ,G ,, {r D-) log <br />Z¢ <br />Transporter 2 Printed/Typed Name Signature Month Day Year <br />G: <br />18. Discrepancy <br />18a. Discrepancy Indication Space ❑ Quantity ❑ Type ❑ Residue ❑ Partial Rejection El Full Rejection <br />Number;ate <br />18b. AlternateFacility (or Generator) U.S. EPA ID Number <br />CJ <br />Facility's Phone: <br />U 18c. Signature of Alternate Facility (or Generator) Month Day Year <br />Z <br />19. Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste treatment; disposal, and recycling systems) <br />( <br />i <br />2. <br />3. <br />4. <br />20. Designated facility Owner or Operator: Certification of receipt of hazardous materials covered by6, manifest exceptes noted in lterr18a <br />Ped dName Signature 9 ,c t ° Month Day Year <br />FPA <br />Form R70f1.99 rRau 3.n51 Pra,A-. -Jifi .- tire ..kms w <br />" - i DESIGNATED FACILITY,TO GENERATOR. <br />