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Please prido'type. (Form designed for use on elite (12 -pitch) typewriter.) <br />Form Approved. OMB No. 2050-0039 <br />LVA I-orm prw;e�,tKqv. ;J-Ub) Frevious editions are obsolete. <br />A - <br />ORM HAZ <br />Generator ID Number <br />2. Page I of <br />3. Emergency Response Phone <br />4. Manifest Tracking Number <br />I <br />WMANIFEST <br />GB�4TE <br />F� <br />5. Generator's Name and Mailing Address (if different than mailing address) <br />6. Transporter 1 Company NameiU.S. EPA ID Number <br />j '- 14 <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 />{11 1,, FA,i.J; INAA I !r --.'N! ;}s3{; -i <br />1XODA,684 AT <br />05 P(I'VVE, <br />Facility's Phone: 2, i 4 -6,'p7 -30f4 <br />ga. <br />9b. U.S. DOT Description (including Proper Shipping Name, Hazard Class, ID Number, <br />10. Containers <br />11. Total <br />112. Unit <br />HM <br />and Packing Group (if any)) <br />No. <br />Quantity <br />Wt.Nol. <br />13. Waste Codes <br />1. <br />RQ UIN 1493 'VOV4 ,'I" Fi A.PA-kAdJi. it <br />J <br />LU <br />0 <br />3. <br />4. <br />1. Special Handling Instructions and Additional Information <br />6-0 1 rt <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 Intemational 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 EPAAcknowledgment 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),Qfl am a small quantity generator) is true. <br />.Slgnatu <br />Generatoes/Offeror's Printedfryped Namere <br />Month Day <br />Year <br />16. InfernatiorR Shipments <br />11 Import to U.S. El Export fro�m;U.S. Port <br />of entry/exit: <br />Transporter signature (for exports only): Date leaving U.S.: <br />17, Transporter Acknowleog ment of Receipt of Materials ry <br />Transporte'(JpPrjnted/T ped Name Signature— <br />Month Dat <br />Year <br />0 <br />CL <br />Z. <br />TraA§§oer PilifildclTryped Na e,- t.,'Sign- <br />Month Day[ <br />ay <br />Fepr <br />18. Discrepancy <br />18a. Discrepandy. Indication Space Quantity ❑ Type D Residue Ll Partial Rejection <br />❑Full Rejection <br />Manifest Reference Number. <br />1.6b. Alternate Facility (or Generator) U.S. EPA ID Number <br />la <br />Af`blllVs Phone: <br />1.0c. $I@ature.Gf.A , lternate.Faclllty (or Generator) <br />Month Day <br />Year <br />T:. <br />hazardous yvask Report Management Method Codes (i.e., codes for hazardous waste treatment, disposal, and recycling systems) <br />A <br />2. <br />3. <br />4. <br />20 Designated Owner or Operator- Certification of receipt of hazardous materials covered by the manifest except is noted in Item 18a <br />Printedfryp6clName i Signature, <br />onth. .Day <br />Year <br />LVA I-orm prw;e�,tKqv. ;J-Ub) Frevious editions are obsolete. <br />