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CD <br /> `< Please prim or Z3 O O Cn <br /> = type.(Form designed for use on elite(I2 pitch)typewriter) Form Approved.OMB No.2050-0039 (D d N <br /> tD <br /> O UNIFORM HAZARDOUS 1.Generator ID Numher 4.Manifest Tracking Nu�%r �� .�-« �WASTE MANIFEST 2 Page I of 3 Eine genry Resp:;#tmnith�n <br /> se PhoneEfTl r�� �S 4 G <br /> = 5 Generators Name and Mailing Address• ^- ,(n ,.� ..Ir,;11 Gen, r ite A. mailing address) CO <br /> '.."'t''�r' f••;pit."I <br /> A.r. !4 irA:'f t;fi::1 N Q <br /> Generators Phone ' (�'+�S 1-4 W <br /> 6. ransporterI vin m0 �u. i:r:'u F`'r'. : - <br /> N y ame <br /> ber @ <br /> U 5.EPA ID Num (D 0 <br /> t Q n <br /> 7 Transporter2Com an :fr",^�. <br /> P y Name <br /> U.S.EPA ID Number � � <br /> N D <br /> 8 Detignated Faahty Name and Site Address <br /> ber =3 (p <br /> U S.EPA ID Num <br /> fv W <br /> (CD v <br /> d r) <br /> FaUdy'c Phone :`)fu_ t <br /> :. <br /> n <br /> ga. gb U.S DDT Descnptron(including Proper Shipping Name,Hazard Class.ID Number, 10.Containers 11.Total 12.Unit — <br /> HAI and Packing Group(if any)) 13.Waste Codes <br /> � 1 No. Type Quantity WtPJoI — <br /> O <br /> uj <br /> LU C <br /> c9 (D <br /> 3. I <br /> 3 <br /> 14 Special HandliAAng Instructions and Additional Information <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 name,and are classified,packaged, <br /> marked and labeled/placarded,and are in all respects in proper condition for transport according to applicable international and national governmental regulations,d 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 /> 1 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/ eror's Printed/Typed Name signature Month Day Year <br /> J 16,International Shipments ❑Import to U.S. ❑Export from U.S. Port of entry/exit: <br /> i— <br /> ? <br /> Transport er si nature for ex its onl : Date leavin U.S.: <br /> 17UJI .Transporter Acknowledgment of Receipt of Materials <br /> Transporter i Pr nted,l yped Name signature Month Day Year <br /> O <br /> CL. Signature <br /> ZTransporter 2 PrinledlTyped Name oath ay Year <br /> r <br /> 18.Discrepancy ❑ <br /> 188.Discrepancy Indication Space Elouanlity Type ❑Residue ❑Partial Rejection ❑Full Rejection <br /> Manifest Reference Number: <br /> Y 18b.Alternate Facility <br /> or Generalor) U.S.EPA 10 Number <br /> J <br /> U <br /> Facili 's Phone: or Generator) Month pay Year <br /> W 18c.Signature of Alternate Facility <br /> r Cis(i e,codes for hazardous waste treatment,disposal,and recycling systems) <br /> sle Report Management Me Codes 3 <br /> 19.Hazardous Wa 2. 4. <br /> (D <br /> 1' i of hazardous materials covered the manifest e>, O <br /> by ceps as rested in Item 18a <br /> pwnar or OPerator:Certification of race P1 Signature C <br /> meted FadNty Day Year <br /> 20.Deft d Name 0 0 13 0 <br /> 0 <br /> c(D printed Y obsolete. GENERATOR'S INITIAL COPY X <br /> ct previous editions are <br /> (n Rev.3 05) o <br /> p A Form 8100 ( (r <br /> _ N_ <br /> � rs <br /> cD <br /> 00 <br />