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Form ADDroved. OMB No. 2050-0039 <br />-- <br />V,- wj 'Y Vc. � W.— — — -1. -.— <br />Generator ID Number <br />2. Page 1 of <br />3. Emergency Response Phone <br />4. Manifest Tracking Number <br />UNIFORM HAZARDOUS <br />f:O) <br />0 <br />WASTE MANIFESTJ <br />5. Generator's Name and Mailing Address Generator's Site Address (if different than mailing address) <br />F <br />V <br />Generators Phone: <br />6. Transporter 1 Comp - any Name U.S. EPA ID Number <br />7. Transporter 2 Company Name U.S. EPA ID Number <br />8. Designated Facility Name and Site Address U.S. EPA ID Number <br />"t- 11+ IT V A I! I sf)e <br />Facility's Phone:' <br />9a. <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. Waste Codes <br />No. <br />Type <br />HIM <br />and Packing Group (if any)) <br />Quantity <br />Wt.Nol. <br />0 <br />1. <br />2. <br />Uj <br />3. <br />4. <br />rF <br />14. Special Handling Instructions and Additional Information <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 />Generatoes/Offeroes Printed/Typed Name 4- signature Month Day Year <br />Z- <br />ri <br />16. International Shipments <br />El Import to U.S. El Export from U.S. Pod of entry/exit: <br />Transporter signature (for exports only): Date leaving U.S.: <br />17. Transporter Acknowledgment of Receipt of Materials <br />Transporter 1 Printed/Typed Name e Signature Month Day Year <br />0 <br />a. <br />Z <br />Transporter 2 Printed/Typed Namq. Signature Month Day year <br />tY <br />18. Discrepancy <br />Space ❑ <br />18a. Discrepancy Indication SpaResidue ❑ Partial Rejection El Full Rejection <br />El Type <br />Quantity <br />Manifest Reference Number: <br />18b. Alternate Facility (or Generator) U.S. EPA ID Number <br />:3 <br />Phone: <br />C3 <br />Lu <br />Fadlity's <br />18c. Signature of Alternate Facility (or Generator) Mo nth Day Yea <br />Z <br />S2 <br />sposo kv,, ir a M) <br />a 45 jqr,bqzaro��t, dil ig Oe <br />U) <br />jq�paze >r _md <br />, , " #R#*,�* ,Qjp�� <br />