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. �y0?3 630 IIIIIIIIIIIIIIIIIIIIIIIIIIIIIfItIIIII <br /> 7 <br /> Please print or Form designed for use on elite 12-pitch typewriter.) 0 0 5 2 6 b 4 7 0 s k 5 <br /> P type.( 9 )�/P ) Form Approved.OMB No.2050-0039 <br /> UNIFORM HAZARDOUS 1,Generator ID Number r��p k't(7` f7'ti.,,;E_ 2.PaNe i of Erb cY nset Ph 4.Manifest Traekln Number <br /> WASTE MANIFEST <br /> `` '` - —_: � 1, 0062n§6470 SKS <br /> 5.Generators Name and Mailin Address Generators Site Address(fdrferent than mailing address) <br /> Ra <br /> t Tt?7^®inaI Ser;.,I s <br /> 1.000 E Moth Rid <br /> F F'[NICH GANEF' cA 9`r-' 1-'000T <br /> Generators Phone: <br /> 1-JT e c p! U,S.EPAID Number <br /> `tY-T_E P V_,7_M.` ,,,fi ?NF fat 205 <br /> 7.Transporter2Corn fl Name U.S.EPA ID Number <br /> G1- -FqN IIAWRS F-NV f Pt 9 itrri'Ti-,I_ SVG` IN ;. • 0. 93?'i'250 <br /> S.Designated Facility Name and Site Address [:E._FAN HARBORS -FAN J(71t;F U.S.EPA ID Number <br /> 11021 PFRRYES3q P{1,'40 <br /> FAN3Il.aE , CP 951.s._e <br /> 414f3-441-0q!")2 C(;I'051494�'1d <br /> FacilHys Phone: <br /> ge 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit <br /> HM and Packing Group(if any)) No. Type Quantity Wt.Nol. 13.Waste Codes <br /> 1.NON RGRA HAZARDOUS WAST}. SOLIDS, C 223 <br /> o (DEBRIS, E`UR.'�l_EG(f, HYDPO gRBONS, <br /> w <br /> Z Z. <br /> w <br /> 0 <br /> 3. <br /> 4. <br /> 14,Special Handling lnstruchonsand Additional lnfannation -1• r:iT 75;35254 RAr^_4E4`tt GSIi: <br /> 24 FIR EMFRGt NCY (SK / Tr:1,i <br /> AJTH AS "AGENT—FCR" RY 5,FN TO RETAIN LICENSFD SLIB CARRIERS A.=; NECES;CSORV <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 labeledlplacarded,and are in all respects in proper condition for transport according to applicable infemabonal and national governmental regulafions.H export shipment and I am the Primary <br /> Export I certify that the contents of this consignment conform to the terms of the attached EPA Acknowledgment of Conse . <br /> ceaify hat the waste fion sta ment identified in 40 CFR 262.27(a)(if I am a large quantity generator)or(b)(V I a small quantity generator)is true. <br /> Generatarsl fferors Print me Signature Month Day Year <br /> IK " <br /> —11 16.Intematio al Shipments <br /> F- L1Import to U.S. ❑Export from U. P f entrylexit <br /> Transporter signature(for exports only): Date eaving U.S. <br /> 17.TranspoderAdmovAedgment of Receipt of Materials <br /> LI <br /> Transporter 1 P'ted/Typed Name Signaw Month Day Year <br /> ram. <br /> yZnlv 11 129 4+ <br /> QTfansporter7 Printedfryped Name Signature Month Day Year <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space Quaintly ❑Type <br /> ❑Residue ❑Partial Rejection El Full Rejection <br /> Manifest Reference Number: <br /> 18b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> U <br /> W Facility's Phone: <br /> W 18c.Signature otAltemate Facility(or Generator) Month Day Year <br /> Q <br /> z <br /> y19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> LU 1. 2. 3. 4. <br /> 1 20.Designated Facility Owner or Operator.Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a <br /> Printedrryped Name Signature Monfh Day Year <br /> EnFo %K 2 (Rgv.3-051 Previous editions are obsolete. DESIGNATED FACILITY TO DESTINATION STATE(IF REQUIRED) <br /> 1??] t ESf� r l 426-63 <br />