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Please print or type.(Form designed for use on elite(12-pitch)typewriter.) Form Approved.OMp UNIFORM HAZARDOUS 1.Generator ID Number hone 2.Page 1 of 3.Emergency Response P 4.Manifest Tracking Number N°•2050{1039; - WASTE MANIFEST i, JJK w. .a 5.Generator's Name and Mailing Address Generator's Site Address(if different than mailing address) Generators Phone:. 6.Transporter 1 Company Name U.S.EPA ID Number 7.Transporter 2 Company Name U.S.EPA ID Number 8.Designated Facility Name and Site Address U.S.EPA ID Number Facility's Phone: :' ' 9a. 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit No.HM and Packing Group(if any)) Type Quantity Wwt./Vol. 13.Waste Codes 0 W 3. 4. i 14.Special Handling Instructions and Additional Information _ kT`; 15. GENERATOWSIOFFEROR'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 labeled/placarded,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 conforn 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. Generatoes/Offeroes Printed/Typed Name a� Signature Month Day Year : . 16.International Shipments I— ❑Import to U.S. ❑Export from U.S. Port of entry/exit: Z Transporter signature(for exports only): Date leaving U.S.: LU 17.TransporterAcknowledgment of Receipt of Materials Transporter 1 Printedlryped Name Signature Month Day Year O n M Transporter 2 Primed(typed Name Signature Month Day Yearr 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 10 Number J_ U W Facility's Phone: C3 18c.Signature of Alternate Facility(or Generator) Month Day Year Q z 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) LU p 1• 2. 3. 4. s 20.Designated Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except as noted in item 18a Printed/ryped Name Signature Month Day Year EPA'Form (Rev.3-0 1 5)i Previous editions are obsolete. DESIGNATED FACILITY'S COPY