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Please print or type. 0 0 6 7 7 6 S Z 3 S K S Farm Approved.OMB No.2050-0039 UNIFORM HAZARDOUS 1.Generator ID Number � 3 � c-;, - 2.Pa f 3.Emer�enc;Resfiense.PlaoRe ;n 4.Manifest Trackin Number WASTE MANIFEST 006 06 7 76322 SKS 5.Ge -Mors N flan j. eiliin Address Generator's Site Address(if different than mailing address) + V I�V c r: -.;ct;' ..rf,`i.� Generator's Phone: I.Tratg top?R9Y +!e 6 :(�Nb ?� U.S.EPA ID Number 7.TrTo e�2 Comp ny Name t F £_ U.S.EPA ID Number 8.Designated facility Name and Site Address c-�fj ir , S g. ' ? 7s s 11,,. r a£ U.S.EPA ID Number Facility's Phone: fga gib.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit and Packing Group if an 13.Waste Codes HM 4 P( Y)) No. Type Quantity WLNoI. I X 1. N- _ w z 2. LU 3. 4. 14 Special Handling Instructions and Additional Information s,-= 7 _%.Z 1 i?u ija `an _YJ ;lir 5 s 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, marked and labeledlplacarded,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 Exporter,I certify that the contents of this consignment conform to the terms of the attached EPA Acknowledgment of Consent. I certify that the waste minimization statement identified in 40 CFR 262.27(a)(if I am a large quantity generator)or(b)(if I am a small quantity generator)is true. Generator'slOfferor's Printedgyped Name Signature Month Day Year IRAw I)J,! tgvr1 1Z1 f C �. 16.International Shipments ❑Import to U.S. ❑Export from U.S. Port of entry/exit, ? Transporter signature(for exports only)', Date leaving U.S.: W 17.Transporter Acknowledgment of Receipt of Materials Transporter 1 Printed Typed N� j Signature Month Day Year a /v ZTranspo 2 PrintedlTyped Name Signature Month Day Year 18.Discrepancy 18a.Discrepancy Indication Space El Quantity ❑Type ❑Residue ❑Partial Rejection ❑Full Rejection Manifest Reference Number: 18b.Alternate Facility(or Generator) U.S.EPA ID Number J U LL Facility's Phone: C3 18c.Signature of Alternate Facility(or Generator) MonthDay Year a 7Z 05 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) 0 1. 12. 3. 4, 20,Designated Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manifest excel noted in Item 18a PrintedlTyped Name r �C Signature Month Day Y EPAFort $ B0 Ar"ous editions are obsolete. DESIGNATED FACILITY/ftPA's e-MANIFEST SYSTEM