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&sxlt,i• 7 L �4 <br /> Please print or type. (Form designed for use on elite (12-pitch) typewriters} <br /> UNIFORM HAZARDOUS <br /> 1 , Generator ID III NIII u 11 mbIIIe11 rIII I Form Approved, OMB Nov 2050.0039 <br /> ! { IIIIIIIIIIIIIIII <br /> 2. Page 1 of 3 Emergency Response Phone 4, Manifest Tracking umber <br /> WASTE MANIFEST t t i ! �) r - <br /> 5. Generator's Name and Mailing , 1 IN t <br /> ) � � x � ti ) )1 ` sr (. IY Generators Site Address (if different than mailing address) <br /> T / t {U A&IO " � 4WE %Idt �?l s ' <br /> Genera hone: 6 `) I'AL: T <br /> 6. Transporter 1 Company Name <br /> ILlcthL7dN" `I $'veo ,: img�rj U.S. EPAIDNumber <br /> 7, Transporter 2 Company Name <br /> r`a 74 <br /> U.S. EPA ID Number <br /> 4 <br /> 8. Designated Facility Name and Site Address <br /> ov : Irmt U.S: EPA ID Number <br /> iL <br /> LOW3 BEAC141 Cid gl 'j <br /> Facility's Phone: ¢ a kY ?F> <br /> 9b. U.S. DOTDescri tion (including Proper <br /> 9a• if ( 9 p Aping Name, Hazard Class, ID Number, 10. Containers <br /> HM and Packing Group (if any)) 10. Containers 12. Unit <br /> 1 , r No, Type Quantity Wt./ft 13, Waste Codes <br /> t"I *l r1721 <br /> c� <br /> '7 (E RFFERIIJ(TD 1VAS"FP V✓a5 A.EC NE7 <br /> 3, use <br /> t'ERASiI'S Gil7l� Tfic,SY, by 7 OSUY 8 OV TON, INC. <br /> WrTH Tiff EN ON rAL PR(YI : DEPARTh1ENI F TOXIC S p QtILIT IND 4 <br /> ITW 3tESOlrRCp CONSERVAT70N A ION AC ACC CILITo UNfl <br /> ACCO NCE WITH OL, TD f?7i <br /> ITDERAL AND SrA7E REGI PECOVFIZY OF 19� PROVISI NS pp <br /> 4 ACCfPr' T TOGEI){g{ <br /> ' r'mRDINGLY ' RFJ3��EN AD D ALL T ) IS ALL OF Np SARYWA j <br /> TE HAS MN IfA <br /> 14. Special Handling Instructions andAdditional Information <br /> 1 ) 021 <br /> 15. GENERATOR'SIOFFEROR'SCERTIFICATION : ( 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 qual generator) or (b) (if I am a small uanti <br /> Generatoe fferor's Print edlfyped Name Q ry generator) is true. <br /> Signature <br /> p Month Day Year <br /> F <br /> , vtt :. r y s ✓ aHa du s; i4 = _W_ P <br /> � 16. Internalional Shipments <br /> ❑ Import to U. S. ❑ Export from U.S. Port ofentry/exit: <br /> Transporter signature (for exports only); <br /> Ll 17. Transporter Acknowledgment of Receipt of Materials Date leav(ng U.S.: <br /> Transporter 1 Printed/fyped Name <br /> O <br /> Signature jT <br /> CL Month Day Year <br /> �' ¢�' ~� � �' .� Itri`'=—a �,,� ,j ' ` - �i.-� '�'b''Transporter 2 FrintedlTyped Name <br /> � Signature �,,� <br /> f- 1110 <br /> Month Day Year <br /> 18. Discrepancy <br /> 18a. Discrepancy Indication Space <br /> ❑ Quantity ❑ Type ❑ Residue <br /> ❑ Partial Rejection ❑ Full Rejection <br /> _ III Alternate Facility {or Generator) Manifest Reference Number. <br /> =r U.S. EPA ID Number <br /> U • <br /> ism Facilitys Phone: <br /> I <br /> LOU 18c. Signature of Alternate Facility (or Generator) <br /> Month Day Year <br /> 19. Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste treatment, disposal, and recycling systems) <br /> LU <br /> 1 <br /> 4, <br /> 20. Deslgnatef d Facility Owner or Operator: Certification of receipt of hazardous materials covered by the manifest except as noted in (tam i8a <br /> PrintedlTypa Name <br /> ,`r 5lgnature y,r' <br /> . , /' p,� { � Month bay ear <br /> EPA For 8 00 ev. 3 D ) Previous editio s are obsolete. � , I <br /> ` � " C1 ECafVAT l F CIt 6 Y Y� C NERATOR <br />