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<br /> Please print or type. momOWEForm Approved. OMB No. 2050.0039
<br /> UNIFORM HAZARDOUS 1 . Generator ID Number 2. Page31 of 3, Emergency Respopse Phone w 4 Manifest Tracking Number
<br /> WASTE MANIFEST r,? e41 r 4: _ "f ` t t r,. a porise
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<br /> 5. Generator's Name and Mailing Address Generator's Site Address (if different than mailing address)
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<br /> Generator's Phone: 1 ' t
<br /> 6, TTgpprortet 1 Comp qny Name U.S. EPA ID Number � o
<br /> 7. Transporter 2 Company Name U.S. EPA ID Number
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<br /> 8. Designated Facility Name and Site Address l " ( # . j-1 ( f f ( si .i-Afj ` yjtl i4: U.S. EPA ID Number
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<br /> Facility's Phone:
<br /> ya 9b. U.S. DOT Description (including Proper Shipping Name, Hazard Class, ID Number, 10, Containers 11 . Total 12. Unit
<br /> 13, Waste Codes
<br /> HM and Packing Group (if any)) No. Type Quantity Wt.Nol.
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<br /> 14. Special Handling Instructions and Additional information r t +=, 1 t• j g Jztfr , i ;t t a . I f g
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<br /> 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,
<br /> marked and labeled/placarded, and are in all respects in proper condition for transport according to applicable international and national governmental regulations. N export shipment and I am the Primary
<br /> Exporter, I certify that the contents of this consignment conform to the terms of the attached EPA Acknowledgment of Consent.
<br /> 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.
<br /> [E;neratoesJOI`ferors Printedfiyped Name, Signature b = Month Day Year
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<br /> 16. International Shipments
<br /> t_I Import to U.S. ❑ Export from U.S. Port of entrylexit:
<br /> ? Transporter signature (for exports only): Date leaving U.S.:
<br /> W 17, Transporter Acknowledgment of Receipt of Materials
<br /> Transporter t Printed/Typed Name SignatureMonth Day Year
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<br /> Transporter 2 Printedfryped Name Signature Month Day Year
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<br /> 18. Discrepancy
<br /> 18a. Discrepancy Indication Space El Quantity ❑ Type ❑ Residue ❑ Partial Rejection ❑ Full Rejection
<br /> Manifest Reference Number.
<br /> 18b, Alternate Facility (or Generator) U.S. EPA ID Number
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<br /> W 18c. Signature of Alternate Facility (or Generator) Month Day Year
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<br /> U) 19. Hazardous Waste Report Management Method Codes (Le., codes for hazardous waste treatment, disposal, and recycling systems)
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<br /> 20, Designated Facility Owner or Operator: Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a
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<br /> EP4 FormX700 22 (Rev. 1217),Previous editions are obsolete. GENERATOR'S INITIAL COPY
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