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UNIFORM HAZARDOUS <br />I- Generator ID Number <br />Page 1 of <br />3. Emergency Response Phone <br />4Manifest T reciting Number <br />9. Generators, Name and Mailing Address Generator's i a Address (if different than mailing address) <br />'6. Transporter I Company Name U.S. EPA ID Number <br />7, Transporter 2 Company Name U.S. EPA It) Number <br />11&1 0001 OW4 <br />B. Designated Facility Name and Site Address U.S. EPA ID Number <br />DR. FAST <br />Facifil (s Phone: <br />ga, <br />9b. U.S. DOT Description (including Proper Shipping Name, Hazard Class, ID Number, <br />10. Containers <br />I I Total <br />12. Unit <br />HM <br />and Pacldng Group (if any)) <br />Quantity <br />Wt.N0L <br />13. Waste Codes <br />No. <br />Type <br />LU <br />3. <br />4. <br />Special Handling Instructions and Additional Informatlon <br />15. GENERATOR'$/OFFEROR'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 fiot 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 EPAAcknowledgment of Consent. <br />I certify ths 9 w6 te minimization statement identified in 40 CFR 262.27(a) (If I am a large quantity generator) or (b) (Ifl aij[_a small-quarifilly generator) is true. <br />Generato'esIONer,b?�.Pfintedrrype,d Name signature Month Day Year <br />61 <br />:_j <br />16. International Shipments <br />Import to U'S. Eprt from U.S. Port <br />cif"erifty/.4t: <br />Transporter signature (for exports only): Date leaving U.S.: <br />17. Transporter Acknowledgment of Receipt of Materials <br />Day <br />Day Ycar <br />18. Discrepancy <br />21e CEM of WeVadia <br />Manifest Reference Number: I <br />- Hvw c,t? 1212-117MIts(s) <br />18b. Alternate Facility (or Generator) <br />ZPT <br />f or, and will OCC9 <br />Facility's Phone: 9peratol' is snipping <br />18c. Signature ofAltem ate Facility -(or Generator) M . ontK-. Day Year <br />Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste treatment, disposal, and recycling systems <br />Designated Facility Owner or Operator: Certification of receipt of hazardous materials covered by the manifest except as noted in item 18a.- <br />Printedqyped Name Signature <br />+ Month Day Yeac <br />