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Please Dint or Noe , Formi desi ned for use on elite 12 itch ewdter. Form A roved . OMB No , 20500039 <br /> UNIFORM HAZARDOUS WASTE MANIFEST zi . umarigninuNumber 12 . P23 . Manifest Tracking Number <br /> ( Condnuauon sheet) CAR 000 247 213 !7 010820480JJK <br /> 2A . GeneatoR Name <br /> SAFEMY 1789 <br /> 25 . TranspMr . Company Name US . EPAIO Number <br /> o <br /> US . EPAIDNumber <br /> 26 , Transporter _ Company Name <br /> 27a , 27b . U . S . DOT Descnwon ( Inoluarg RoperShipping Name , Heated! pass , ID Number, 23 . CaNainers 29 , Total 30 , Unit 31 , Waste Giles <br /> HNt aNl) re Grantuanyll No . Typo Quantity MNol . <br /> Waste05 KQ e I nes , so CM C , n . o . s . es Ue <br /> Last Contained : Warfarin ) , 8 . 1 , PGII , RQ (P00 % ERG * 151 <br /> Oil Non =KCKA Hazardous Waste , Liquid ( consumer Pro u s <br /> 07 on on egu e m mms <br /> 0 <br /> u <br /> IA 10 <br /> STFD BOTTLES I The weight of empty P- listed waste containers was net Included in determining this <br /> penaysIDr• s Simne , Residua les : QOO89 B . A13SNHMI / ABSNHK01 - NONHAZARDOUS LIQUIDS & SOLIDS TABSNHN041ASSNIVIVII <br /> CRA EMPTY CONTAINERS <br /> 33 . TransporterPrkwwle menton of Ma & nals <br /> U.1 Fort read Name 3gnaNre Month Day Year <br /> K <br /> O <br /> 2 34 . 1tans net mentafRetselptof Matanals <br /> FiredNypeb Name Signature Mon Day Year <br /> 35 . Discrepancy <br /> u <br /> fJL <br /> 36UUgavrO 41 Report Management Welbon Utles44 wtles fa hanot mewasteW enk sYandrerydingsysRms) <br /> no <br /> EPAForm8701DIIMRev. 3 - 05 ) Previouseddii onslamobbsolete . 13 1 ' 1DESIGNATED FACILITYTO DESTINATION STATE ( IF REQUIRED ) <br />