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Please print or type. Form Approved, OMB No, 2050.0039 <br /> UNIFORM HAZARDOUS 1 % Generator ID Number 2. Page 1 of 3. Emergency Response Phone 14. Manifest Tracking N - <br /> umber 23 <br /> ! _. '_I. k ( 'k <br /> WASTE MANIFEST '-' �k � - JJ K <br /> 5. Caenll(ator's Nye and Mailing �ddress :rt i r . i Generator's Site Address (if different than mailing address) <br /> Generator's Phone: iS e <br /> 6r jiansporter 1 Company Name U .S. EPA ID Number <br /> �.a � _1_Ltf`-1 <br /> 7. Transporter 2 Company Name � ILU. .S. EPA ID Number <br /> 8. DqsigI .V a ili ffp nd ggr Address U.S. EPA ID Number <br /> I " 4 <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)) 13. Waste Codes <br /> { <br /> No. Type Quantity Wt.Nol, <br /> ad �' <br /> z 2. C <br /> ,t <br /> Wa ... r .. „/ p $'.,. F -s' s, <br /> j, 171 <br /> 3. A 0A E � �'{ fS 3ke. � . , �✓�0.� ` .a fAs :l1 r , ' "j �3 <br /> ff <br /> 4. <br /> d <br /> 14 Special Handling Instructions and Additional Information 7 r <br /> 1) ° �yy� �, .e.�; . ,, k .rf `t <br /> 15. GENERATOR'SIOFFEROR'S CERTIFICATION; I hereby declare that the contents of this consignment are fully and accurately described above by the proper shipping-fiame, and are classified, packaged, <br /> marked and labeledlplacarded, and are in all respects in proper condition for transport according to applicable international and national governmental regulations. If export shipment and I am the Primary <br /> Exporter, I certify that the contents of this consignment conform to the terms of the attached EPAAcknowledgment of Consent. <br /> I certify that the waste minimization statement identified in 40 CFR 262.27(a) (if i am a large quantity generator) or (b) tiff am a small quantity generator) is true. <br /> r7neratcrs/Offeroes Printedrryped Name Signature Month Day Year <br /> 16. International Shipments <br /> ❑ Import to U.S. El Export from U .S. Port of entrylexil: <br /> Z Transporter signature (for experts only): Date leaving U.S.: <br /> W 17. TransporterAcknowledgment of Receipt of Materials <br /> Uj <br /> Transporter t Printedrryped Name } Signature Month Day Year <br /> CLu. <br /> zTransporter 2 Prinitedrryod Name Signature Month Dray Year <br /> F <br /> 18, Discrepancy <br /> 18a. Discrepancy Indication Space Ll Ouantit <br /> y ❑ -ype ❑ Residue ❑ Partial Full Rejection <br /> WA3C$ WAS RELMU). HANDl.E7) AND STORED POR SU UNDO <br /> Clil R►f6T�r4 1 C. Of?77tAat SAME CF CONTRO.TOGb' <br /> 18b. Alternate Facility (or Generator) 0111100 DEPAR <br /> J i tgRAi rtT ' ®Y [ CN AGFltCY P1 ACCORDANtlE6W8WA11 �A1111i <br /> U Cr OF 19 <br /> {� �1VtRDH � pRpZ F TI COVERY A16 TOGE71� TtiR NECaSSARY <br /> Facility's Phone: AURCB CW4** VEOU1,A'i1GNS . 'CROSBY kO A I- TtfH SO HA 1'E HAS SF];N'"AND1 irk <br /> W 18c. Signature of Altemate Facility (or Generator) t � y W ACCEPT Month Day Year <br /> Z1Rpgy(p Y <br /> 19, Hazardous Waste Report Management Method Codes (Le., codes for hazardous waste treatment, disposal, and recycling systems) <br /> 0 12 , 3. 4 , <br /> 20, Designated Facility Owner pr Operator: Certification otreceiphof hazardo" materials covered by the manifest except as noted in Item 183 <br /> Printedffyped NaIt <br /> m' s ` t t f Signature - w - , Month Day Year <br /> i ' d <br /> EPA Form 870042- Re'v. 1247) Previous editions are obsolete _, DESIGNATED FACILITYTO GENERATOR <br />