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Please Print or Iv 'Form designed C. <br /> tyre.- d for use on elite(1 2-pitch)typewriter) <br /> UNIFORM HAZARDOUS I I,Generator!D Numb 11 er Form Approved.01VIB No.2v50 u039 <br /> Page 1 of 3,Emergency Response Phone 14,Manifest Tracking Number <br /> WASTEMANIFEST <br /> 5 Generators Na, 1 010168088 FSE <br /> and.Meiling Address Generators Site Address�;fdifferent tban mailing addressi - <br /> 3 - <br /> Generator's Phone. <br /> b <br /> anspoFfer 1 Company Name <br /> U.S.EPA ID Number <br /> T T rairsporter 2 Company Name <br /> EPA,ID Numbr <br /> 8.Designated Facility Name and Site Address <br /> U S.EPA ID Number <br /> Fac;Ii4i`s Phone: Q <br /> 9a. 3b.U.S.DOT Description(including Roper Shipping Name Hazard Class,ID NImbe,, Containers 11. Q Unit <br /> L-111M and Packing Group(if any)) 13.Waste Codes <br /> No. Ty Quantity <br /> Type "Tt"Voi. <br /> 0 <br /> LLJ <br /> -7.77 1 Z t <br /> LLI <br /> Fy <br /> 4Q0 0,n:Z"r, <br /> 'S <br /> a in <br /> t <br /> I <br /> _7477pecial Handling Instructions and Additiona- Mn11 atiOn <br /> 105 1 F <br /> 05 17 'R z-k <br /> J GENERATOR' F— <br /> SPICIFFEROR'S CERTIFICATION: I hereby declare thatthecontents of this consignment are fully and accurately described above by the proper shipping name,and are classified, <br /> marked and labelediplacaided,and are in all respects in proper condifi0r,fortlansport according ;e internaanalnational aovemmental regulations.applicabl packaged, <br /> If export and I am the Primary <br /> Exporter,I cert!ly that the contents of this consignment conform to the terms of the attached EPAAcknowledgment of Consent. <br /> I certify that the waste minimization statement identified in 40 CFR 262.27(a)(if iarn a large quantity generator)or(b)(if I am a small quantity gererator)lls true. <br /> G tators[OfferorIs yped Name =qnature- Month Uay Year <br /> re <br /> �j 16.International Shipments <br /> 01 Ailporl to U.S Export U.S. Port of err/exit: <br /> Transporter signature,for exports only): <br /> Data ie&4 Ti.s <br /> w17,T,ransporter Acknowledgment of Receipt of Materials <br /> Transporter I PrintediTyped Name Signature, Month Uav ear <br /> 00 <br /> Z T,•ansporter 2 Printed!Typed Name <br /> ls�n alure Month l7ay Year <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space <br /> El Quantity aType L-11 Residue Partial Retection Elcluil Reiecuon <br /> I <br /> klanifest Reference Number: <br /> 18b.Alternate Facility(or Generator) <br /> U.S.EPA ID Number <br /> I's Phone' <br /> L <br /> LLJ Facility(or Genera'tor) "I Day <br /> 4c <br /> K Sio.,7777 Alternate Year <br /> Z <br /> 1 <br /> 9,Hazardous Waste Report Management Me`hod Codes des(i.e.,collets for hazardous waste treatment,disposal,and recychng systems) <br /> Uj I H-13, 4- <br /> 20.Designated Facility Owner or Operator:llertifilcaron of receipt of hazardous materials covered by <br /> the manifest except as noted in Item 18a <br /> Pr. Tvped Name Signature Doth Day ear <br /> EPA For 870 i-22(R v.1-05) Previous dio.s are obsolete. AT'r-*"37 E'IF REQUIRED) <br />