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/ . <br /> Jill se plini or tVpe. Form Approved.OMB No.2050-0039 <br /> 1,Generator ID Number 2.Page I of 3.kmorpKy RBsponsu Phone 4,manifost TrapKing N Limbor <br /> UNIFORM HAZARDOUS <br /> WASTE MANIFEST GBF <br /> Generators <br /> 8 U.S.EPA 10 Number <br /> 9a. gh.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number. 10.Contai ers 11.Total 12.Unit 13.Waste Codes <br /> HIM and Packing Group ffany)) No. Type Quantity WI.Nol. <br /> 1. <br /> LU <br /> 3. <br /> 15. GENERATORVOIFFEROR'S 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, <br /> marked and labeledfplaoarded,and are in all respects in proper condition for transport according to applicable international and nalional governmental regulations.If export shipment and I am the Primary <br /> Exporter,I certify that the contents of this consignment conform to the terms of the attached EPA Acknowledgment of Consent. <br /> I certify[hat the waste minimization statement identified in 40 CFIR 262.21(a)(if I am a large qua n lity generator)or(b)(If I am a small cute rillty generator)is(rue. <br /> _j 113.1riternalkinalSAipmebts <br /> -0 Import to U.S, Export from U.S. Port of enlrylexit: <br /> Transporter signature(for exports only): Date leaving U.S.: <br /> 17.Transporter Acknowledgment of Receipt of Materials <br /> Tran <br /> 18.ClHrapanq <br /> 18a,Discrepancy Indication Space 0 QuantIty El Type Residue Partial Rejection Full Rejection <br /> 18b.Allemale Facility(or Generator) 1.0.EPA ID Number <br /> rocIIIIA Phone: <br /> It'.Hazardous Waste Repad HBMConioni Method Codes(i.e.,codes for hazardous waste treatment,d1spaiial,and nqcyclpn�SYMOMS) <br /> UJI Notice:State of California requires <br /> generator ouphotocopy and mail nz <br /> 21J. Ownerof Operator:Codification of receipt of hazardous materials covered bythe manlfes[Gx�qi asnoledin Iter DTSCwith 5Odays. I <br /> __ <br /> P.OBox400 ;-87 <br /> Sacramento, CA958l%'0u0O . <br />