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7 1 J 9 4.)b 0 1 .11 <br /> Please print or type. <br /> Form Approved.OMB No.2050.0039 <br /> UNIFORM HAZARDOUS 11,Generator ID Number 2.Page 1 of 3.Emergency Response Phone 14.Manifest Tracking Number <br /> I A. <br /> WASTE MANIFEST I G 01 0 0t G 9 'i') 5 G, vi 5 3 7 F L E <br /> 1 0 14 2 <br /> Generator's5. Name and Mailing Address Generator's Site Address(if different than mailing address) <br /> A E <br /> Ge ne rator's Phone:I <br /> 6.Transporter 1 Company Name U.S.EPA ID Number <br /> N1 A i-D 0 3 Ci <br /> 7.Transporter 2 Company Name U.S.EPA ID Numbe6, <br /> J1 <br /> 8.Designated Facility Name and Site Address U.S.EPA ID Number <br /> CA T`�iz-)G <br /> Facility's Phone: <br /> 9a. 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, `10.Containers 11 Total 12.Unit <br /> HM and Packing Group(if any)) No. Typo Quantity. Wt.Nol. 13.Waste Codes <br /> 1.r <br /> �Y` <br /> \J <br /> M 2. <br /> UJ <br /> 3. <br /> 4. <br /> 14.S lj%J�Q <br /> Ipcfions and Additional Information <br /> 15. GENERATOR'SIOFFEROR'SCERT FICATION: I hereby declare that the contents of this consignment are fully and accurately described above by the proper shipping narrt6,)ard are classified,packaged, <br /> marked and labeled/placarded,and are in all respects in proper condition for transport according to applicable internat'ionaland national governLnental.regulatlo'ns.If export shipment and I am the Primary <br /> Exorter,I certify that the contents of this consignment conform to the terms of the attached EPA Acknowledgment of Cnsent. <br /> 1,60ify that the waste minimization statement identified in 40 CFR 262.27(a)(if I am a large quantity generator) ?ill amla-small�,,,)titige,n'feratior)i4ue. <br /> ,Genorator's/OffQrdr`s Printed/Typed Name signature,/, <br /> Month Day Year <br /> _j 16(International Shipment 6 <br /> Import to U.S. El Export fror�U.d' Portof entry/exit: <br /> it ansporter signature(for exRqqq-q-R1y): Date IeaVing,U,S,i. <br /> Luk.17.Transporter Acknopiedgment of ReceiR"Of Materials <br /> . <br /> I <br /> ,Transport r 1 Prime YP d'NampMonthnature Day (ear- <br /> 0 <br /> Signature <br /> ZZ Transporter 2 Printed[Typed Name Month Day Year <br /> 18,Discrepancy ✓ <br /> 18a.Discrepancy Indication SpaceQuantity <br /> F Type 0 Residue 1:11Pa41�'ill Rejectiorl.',,' El Full Rejection <br /> Manifest Reference Number: <br /> 18b.Alternate Facility(or Generator) US.EPA ID Number <br /> Zi <br /> LL Facility's Phone: <br /> C3 <br /> LLj 18c.Signature of Alternate Facility(or Generator) Month Day Year <br /> Z <br /> 0 <br /> 7,- 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> 2. 3. 4. <br /> 20.Designated Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a <br /> Printed/Typed NameCSignature M nth Day Year-1 0TUCV (J((9 <br /> EPA Form 700-qj(R€rv.12,17) �qvious editions are obsolete. 51 FACILITYTO GENERATOR <br /> ,t, .,tars' <br /> ,,I.DE GNATED <br />