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i <br /> i <br /> R4 1..) Y rr LI rr�{r � ���r� <br /> Please print or type.(Form designed for use on(lila(Ii Z,pitch)typewriter.) Form Approved.OMB No.2050-0039 <br /> I,Generator ID umb r <br /> UNIFORM HAZARDOUS 2 Pagn 1 u1 3.Emergency Response Phone d.Manifest Trackin Number �'"'' <br /> WASTE MANIFEST (:is i 11•�1:"f �r; ' °('�.j. "' Fj a' ' 0 1,.�. 2 1'''' <br /> .a.. P.J.!»�: LE <br /> 3.Generator's Nano and Milling AddresS e:ce Genemloes Silo Address if different than mailing address) <br /> F <br /> Generator's Phone <br /> tiran porter 1 CompanyName S.EPA ID Number <br /> i?' '^•h+Y , <br /> 7.Transporter 2 Company Name U,S,EPA ID Number <br /> WR Ply fol;Art' ii ,11L is r' 1;,{l-.y ( i't�'} '`•i`." _i: ' r''i <br /> 6.Designated Facility Name and Sile Address <br /> U.S.EPA ID Number <br /> Al tl�•i"'w,�'i•' uY r.`•4. ' { r�,( R,t } i .i,Y,} <br /> Facility's Phone: <br /> ga, 9b.U.S.DOT Description(Including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12:Unit <br /> and Packing.Group(if any)) 13.Waste Codes' <br /> HM � �No. Type Quantity Wt1VoI. <br /> 1 y Irl i�i,i t �rlt� <br /> 0 f ., - .� f�i tY, 1:.r r•7_lt., d?„ '1.. ,� ��w•i^> .. ,.,.�, <br /> 4. <br /> 14.Special Handling Instructions and Additional Infol malic4l <br /> f`5.'�GENERATbR'SfbP9E12S 'S C9R IFICAT(OF:1'li�Tbby dbclare jftat1h cdnt9ni 1 itit§'ddnsi§iim9at afe`fui y.aitd accdraiblydek'ribed'dbo4'13) pTbpb�§hipping name,and are classified;packaged, <br /> marked and labeledlpfacarded,and are In all re pact$$in proper condition for transport according to applicable International and national governmental regulations.If export shipment and I am the Primary <br /> Exporter,I certify that the contents of this consignmedI conform to the terms of the attached EPAAcknowledgment of Consent. <br /> 'i co lfy that the waste minimization statement ideniifl;d in d0 GFR 262.27(x)(if I am a large quantity ggacator•qr(b)(if.t a a small quanti generator)Iva <br /> enerato oror s Pfinte/typed Name. —sign a—�J r on ay ear <br /> —r 16.International Shipments s <br /> F— ❑Import to .S. ❑Export from U.S, ort of entrylexiC <br /> Trans oriersl nature(forex ortsonl : ateleavinctU,S,: <br /> w 17:TransporterAcknowledgment of Receipt of Materials ,•'' <br /> Trans p Pdnted(rypedName /9q/sfr�ra; cn1 ayty <br /> Year <br /> er2Printed yperf ame tp aMonth <br /> 18.Discrepancy <br /> 199.Discrepancy Indication Space Q quantity ❑Type ❑Residue <br /> ❑Partial Rejection t.1 Full Rejection <br /> i <br /> Manifest Reference Number: <br /> 18h.Alternate Fadlily(orGenerator) i U.S.EPA 10 Number <br /> J <br /> u- Facility's Phone: <br /> LU 18c.Signature of Alternate Facility(or Generator) <br /> Month Day Year <br /> 19,Hazardous Waste Report Management Method Co es(•.o.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> 2 3. ^, <br /> 1 <br /> 20.Designated Facility(hurter or DparalorIn <br /> of r coipt of hazardous materials covered by the manliest a Fept as noted in Item 18a <br /> Print Nanta 44((•• _ Signature € yy J Month Day Year <br /> NJ, k. <br /> EPA Form 870022(Rev,3.05) Previous eobsiolate. DE51 ;TSD FACILITY TO GENERATOR <br /> I <br />