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�JVFD <br /> Please print or type.(Form designed for use on eift�(-I 2,-p(tch)typewriter.) Form Approved.OMB No.2050-0039 <br /> UNIFORM HAZARDOUS 1.Generator ID Nur bartosporis0h one 4.Manifest Tracking Number <br /> WASTE MANIFEST • o E[-1,"E�F' .C)J,1 <br /> 1 5 5 19 J.9, 1 FLE <br /> 7—Ganerelor's Name and Mailing Address I Generator's SileAddresF(if different than mailing address) <br /> 4 <br /> 15'E'i 21, (11 <br /> 6,Transporter 1 Company Namo U.S.EPA ID Number <br /> 1.",_,; 1-EC'ys vi:lfi- <br /> E <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> ('i ).1P11JT3 LD fl'!:" E N 1 y 117, <br /> 8,Designated Facility Name and Site Address I U.S.EPA-15 Number <br /> Facility's Phone; 4 1 <br /> 90. 9b.U.S.DOT Description(including Proper hippi g Name,Hazard C16ss,ID Number, 4N 10,Contalrers 11.Total 12.Unit 13,Waste Codes <br /> HM and Packing Group I No, Type Quantity VVI'lVol, <br /> ce <br /> Si)e <br /> Z 2. <br /> Lu <br /> 0 <br /> 3 <br /> i 0 <br /> YLI" <br /> 14,Special Handling Instructions and Additional inter Mallin n T 3"1.1 17 1" <br /> eCH "'iK I T T <br /> NO-4ra'p-- <br /> 24 F'R E'NU ' <br /> t Q M <br /> �V, �W16�-In name,and are das�slrjed,packaged, <br /> 15"GENERt�tOR'Slb SER 1t'SGER.IFICA710 'fibrbliy d6fte Wrgid Z 't1fdrit titly Fd0ddjU�,,Xldbr ab,T. <br /> marked and labeled/plac 11 peci�in proper condition for transport according to applicable Inlemational and national governmental regulations.If export shipment and I am the Primary <br /> Exporter,I ceftilythat tho contents otims consiontru t conform to the terms of the attached EPAAcknowledgment of Consent <br /> ,+oq�lfy that the waste minimization statement IrIentilled in 40 CFR 26127(a)(if I am a large quantity generat�jor.(b)(if I am small quanliv ro"nefator <br /> '4121 Vs true, <br /> Gort. lator's101 Oror`$Pnote/T ped Naft Mon lh Da ear <br /> -j 16,International Shipment <br /> ElImport t U.16. t.1 Expert from U.8. Pgjf,ritryloxil: <br /> Transporter siqnature for exports only): Date leaving U.S.: <br /> W 17.Transporter Acknowledgment of Receipt of Mated-Is <br /> Uj <br /> Transp Pn todfryped Name bgriatupe- M-on-Y--Uay Year <br /> 0 0- <br /> 'ear <br /> '�2 PdntedfFyped Name Signal <br /> Oro'4&')') 1 �7�1'� ?? <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space Qumiliy 0 Type EJ Residue ❑Partial Rejection ❑Full kaloctim, <br /> Manifest Reference Number: <br /> 185.Allematp Facility(a?Generator) I U.S,EPA ID Number <br /> u<- Facility's Phone: <br /> 0 18c.Signature of Alternate Facility(or Generator) Month Day Year <br /> Uj <br /> Z <br /> 19-Hazardous Waste Report Mannergent hie.thod qodes(i,o.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> fl T-- 2, <br /> y <br /> z20.Designated Facljly Owner orpporalor:�011ilicafion ocovered by the manifest except appled.In llem)Ba <br /> Prince F!Aed Na o Signatureo ttr a <br /> XY <br /> FPA r e r(Tf87 0 0.22(Rev,3-8) Previous editions 1're o�osolete, DESIGNATED FACILITY TO GENERATOR <br />