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P <br /> p type (Form das 1for sin sulfa ti <br /> Please runt ar t2 pitch)=tyewmterj Form Approved t�M13rla #i5.f3039 <br /> 11NIFORh MA o is Ga D"Nuirt4rer . 2.Pap l of 3:Em ency Responsa,Phone; a tTr Nmnber <br /> -CAL 040019 5 914 6 <br /> 5.Genii toes t ' e andnaliing Addr e�sara or s wdr .�rFdltfierent raa ma�ttng aaaress) <br /> Vii <br /> � � f � <br /> ':' <br /> ysun <br /> ., ;Genaratoes:Phone: <br /> 6i rahsporkerltCo `p ny Name C7 3 EPA1D Number <br /> �.. _ <br /> 7.Transporter 2'6rrp hy}Naroe Number <br /> 8.tDe�_ FiOat Med ' 6 t,€ 'tby Name and itg,Address U:S,.EPA ID Number <br /> t7i#i <br /> "(60 <br /> l) '+ .6200 {m'A 98 0 67 52`" <br /> Facility's Phone: <br /> ga. 9b.U.S.DOT Descript;on(including Proper Shipping Name,Hazard,Class,10 ,11,Total , t2•Unit �'18:1Vasta Codas <br /> HM and Packing Group(if any)) , Type Quantity WtlVoi,, <br /> 1. <br /> n ('+NONE .74" .A Hazardous Wr ask,, ids-,(Le-W,j f OT 1 8 <br /> LU <br /> 2. <br /> LUR <br /> 3 <br /> 4 <br /> i <br /> 14.Special Handling Instructions and Additional Information <br /> &)it: 95-1001% Cleart ffwbors Protan; Munber, C 4A-3 12 3 0 <br /> -5% t u°ap 'c rs:c r.1� a t . rc t f EquiplierAasowessary <br /> 15. GENERATOR'SfOFFEROR'S CERTIFICATION:-I hereby declare that the contents of this consignment are fully and accurately described above by fie pW shipping name,Ord are ' <br /> marked and labeled/placarded,and are in all respects in proper condition for transport according to applicable international and national govemmental r s.If export'shipment and I am the PnmOry <br /> Exporter,I certify that the contents of this consignment conform to the terms of the attached EPA Acknowledgment of Consent. <br /> I certify that the waste minimization statement identified in 40 CFR 262.27(a)(if I am a large quantity generator)or(b)(if I am a small quantity generator)is true. <br /> Generators/Offerors PrintediTyped Name Signature r Month. Day " Year <br /> ( t_iftw city of m t1) 1" <br /> —r 16.international Shipments <br /> Z ❑Import to U.S. ❑Export from U.S. Port oftry/exit: <br /> Transporter signature(for exports only): Date Iea'ng U.S.: <br /> 17.Transporter Acknowledgment of Receipt of Materials <br /> Transp ra f'Printed/7yped Name SignatureMonth Day Year <br /> . ". <br /> Q Transp iter 2 Print ped Name kWM Vay Year <br /> F- <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space ❑ Quantity ❑type ❑Residue ❑Partial Reiaction ❑Full Rejection" <br /> Manifest Reference:Number. <br /> 18b.Alternate Facility(or Generator) j U.S.EPA ID Number <br /> J <br /> t3 <br /> W Facility's Phone: <br /> w 18c.Signature of Alternate Facility(or Generator) Month Day Year <br /> � Y <br /> 19.Hazardous Waste Report Management Method Godes(i.e.,codes for hazardous waste treatment,disposal,and recycling"systems) <br /> 0 1112 1 1 <br /> IV3. 4• <br /> •J t . <br /> 20.Designated Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except as nded in Item 18a <br /> Printedfryped Name Signature Month Day Year <br /> FPA:Pnrm Vnn-99 Mov i-nrn`Pre trnuc—w;nne aro rho lntn' <br />