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Its i Please print or type, (Foran designed for use on elile (12-plich) typewriter.) Form Approved. OMB No. 20500039 UNIFORM HAZARDOUS 1 , Generator ID Number v 2. Page 1 of 3. Emergency Response Phone 4. Manifest Tracking Number CHASTE MANIFEST 1r - 4VJ t 1'V'`.] '� � c 015 2 7 7 64 O J J K � t S. Generat fs Name and Mallin Address v � ` O .'"S s Generators Site Addressur different than mewling address) Mating J C, .. ) _�J; 17 I e'll Z` `L �TGenemiois Phone; Yr � ` F 6. Transpo er 1 Company Name U.S. EQAfD Number J } A "r f U.S. EPA ID Number a3 7. Transporter 2 Company Name �v \ vo C� 106 d 2e U513 j Ce/.�Dl��,IrgG��la1 dFacility Name and SiteAddress U.S. EPAID Number 6 �?C+f��6� S ��L�� %••C„�(.ta� ��'2�4r.L"4., f:/YTT � 7�..� f7 r'^.s ��./ Facilliys Phone gy 9b. U.S. DOT Description (including Proper Shipping Name, Hazard Class, ID Number, 10, Comainam 11. Total 12. Unit 73. Waste Codes HM and �Packing Group (if any)) No. Type Quantity WLNoi, w f) . L e ai d yc� `aC� Y Car M 2. _CD ... 4 - 3. i 4. / 14. Special Handling lnsuuclions andAddBional Information oq i 15, GENERATOR'SIGFFEROWSCERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by the proper shipping name, and are classified, packaged, marked and labeled!placarded, and are in all respects In proper condition for transport according Is applicable International and national go emmental regulations. If export shipment and l am the Primary Exporter, I certify that the conlenls of(his consignment confomr to the terms of the attached EPAAcer mwledgment of Consent I angry (he[ the waste minimization statement identified In 40 CFR 262,27(a) (if am a large quanhty generator) or (b) flemasmaliqu lityge ator) istme, GenemtofslOfierors Pdnled7Typed Name Signature Month Day Year ie. lnt no n Shipments ❑ Import to U.S. ❑ Export from U.S. Port of enlrylexii: � Transporter signature (forex ods only): Date leaving U.S.: er 17. TranspoderAcknovAedgmenl of Receipt of Materials T r 1 PdnledlTy�,pend Name SI Month Day Year T� �iMonth D year ZIp nor 2 Farrow types Name � 06111 1L Q 18. Discrepancy Tier Discrepancy Indication Space ❑ Quantity ❑ Type ❑ Residue ❑ Partial Rejection ❑ Fui Reintarn Manifest Reference Number: h„ iSh. Aieu _s Facility (or Generator) 0.S. EPAID Number V rdr- Faclllty's Phone: 0 18c. Signature ofAllernate Falaity (or Generator) Month Day Year k a C9 19. Hazardous Waste Hoped Manag ment Method Codes (i.e., codes for hazardous waste fizaMenk disposal, and recycling systems) ( d 1. 2, 3, 14. 20. Designated aciligrownero Ope star: Codification of recelpt of hazardous materials covered by the manifest except as noted in Item 18a Priniminyped Name !} > , Signature Month YeN EPA Form 0700- v. 3-0 Previous editions are obsolete. DES102HATED VT TFN{t1'EC}N STAT (IF REQUIRED)