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Pleaserintort p type.(Form designed for use on elite(12-pifCh)typewriter.) � Form Approved.OMB No.2050-0039 UNIFORM HAZARDOUS 1-Generator ID Number 2.Page 1 of 3.Emergency Response Phone 4.Manifest TrackingNumber WASTE MANIFEST I '�' [t. 'i�'t i ! .7 ,�.- _ 00880144 FLE 5.Generator's Name and Mailing Address µ Generator's Site Address(if different than mailing address) # vii Jtml wEnei-31 1.:: �' �_:fls_ It � 31e 64 i:vii t�:: 111AIN STREET 1iR01 SAES T i"iA IN S,T REE Generator's Phone: r:i ard. -{ };J,��[�, .,t,L�r_:' r31 r,;i Lp, 6.Transporter 1 Company Name U.S.EPA ID Number "9'kY J ,;.LJ � e:Ir._irA_:Ii;• t..:._.!r ..L..-_=.i`J .�il� j1 :�i.c .-,tip . tis-/ 7,Transporter 2 Company Name r _ U.S.EPA ID Number B.Designated Facility Name and Site Address i,1 St LzenifurY EMN, LLL U.S.EPA ID Number 101, iY:ri�. Vj iY 4'l.'1cT G C Facility's Phone • "5 5 a� Etc 9a, 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11-Total 12.Unit 13.Waste Codes HM and Packing Group(if any)) No. Type Quantity Wt.Nol. n 1JU041'j'Q Wast" el-GEO S, adilmae 2. 1, EPG-4#126 i Ui?4 tt � r' `:.3A, O a W 2f,4c-`, 1'lCRA hazaY0Cit it-i t e. S Y iji d o s!-iM aI- r 4e1 i�u - O P-1-0duct_1, 31v10T K;-KH nazar' Gras waste, s0 1n ,--o115Uiiter c_ L-t= 00053 P 331 Pi uuuF t s, . 4 14 Special Handling Instructions and Additional Information .l, L 105 t j ;F1 a C-i s 10'; 4 f N o n_'CRA E i q i_3.d vi d�� LCA iO;i j y -- f�GfeGa�k! . 11052 (IkVfi- %AS '011G W ste '.'4H C;P, �; ( noFec:._t l 15. GEWE1111'fMV0FFMR1 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 conform to the terms of the attached EPAAcknowledgment 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)('d I am a small quantity generator)is he. Ce V0111f=s PhiftdrTyped g�Name iggn/atureon ay Year !r1 �Le�rrt I /� I 1LA L1sIe 3t 1f.international Shipments Z ❑Import to U.S. ❑Export fl U.S. Port ntry/ext Transporter signature(for exports only): Date civ ng S.: W 17.Transporter Acknowledgment of Receipt of Materials a: Transporter 1 Printed(ryped Name S gnf ture r Month Day Year CR Ant,"ienv MA- I l /Vi 11�fA ( At---, I ;' I `~nom: 12:—, N z Transporter 2 Printed/Typed Name Signature Month Day Year r- 18.Discrepancy ' 18a.Discrepancy Indication Space 0ty ❑Type ❑ ❑ I ❑Full Rejection Quantity e Residue Partial Rejection Manifest Reference Number: 18b.Alternate Facility(or Generator) U.S.EPA ID Number J_ V LL Facility's Phone: I w 18c.Signature of Alternate Facility(or Generator) Month Day Year Q z I I I 19,Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) C 1. 12. I3 4. 20.DesignatedF cility Owner or Operator.Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a Printed/TM'� C- ,\npor Signature Month Day Year ( 0,kc) A EPA Form 875500 22(Rev.3-05) Previous editions are obsolete. DESIGN AnIlITY TO DESTINATION STATE(IF RE( UIRED) B700. -21-:2 t ._ "HH >W'y1v,�[L.'k .tC' ��41053:.-;=! �t09i4r_ 4r• M 31-"i,