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Please print or Noe. (Form desioned for use on elite -1.12 -Ditch) tvoewrite'rg'_Ll - <br />A± T Form Approved. OMB No. 2050-0039 <br />tvA "n -n utuu-a lKev. j-uo)• f:revious editions are qcisoiete. 1, <br />X: DESIGNATED FACILITY TO GENERATOR <br />I-IAm hA5 nhe -am4maif" pni-PiT.'s hT mm?l W1 ;-,0eA,;2 AA� risco w1attyr M-SN-oi, <br />UNIFORM HAZARDOUS <br />1, Generator ID Numberge <br />1 of <br />3. Emergency Response Phone -4. <br />- lFest Tracking Number ` <br />f7, <br />-t C" r <br />WASTE MANIFEST <br />4 <br />f�n rli, <br />, <br />FLE <br />5. Generator's Name and Mailing Address GdFeTat6r's Sitd'Addre-s§ (f-difterent,than mating address) <br />Ryir,g ; Trayet Pic z x Oill "o <br />6: Transporter 1 Company Name, U.S. EPA ID Number <br />SSFilr-75 0-3,1e, <br />7. Transporter 2 Company Name U.S. EaATb Turn <br />8. Designated Facility Name and Site Address U.S. EPA ID Number <br />g NameHazard Class,'ID Number, *--- <br />9b.'IJZ. DOT Descriple; n�cl-,',;,�ngPop.-�S-�pp., , <br />'Padding <br />10. Containers <br />11I.Total <br />12- Unit <br />13. Waste Codes <br />No. <br />Type <br />HIM <br />and Qoup (if any)) <br />Quantity <br />-,WbVQI. <br />0 <br />WAST E. !X�L.15S­ tWR_3(-L` <br />UZ <br />t <br />LU <br />Z <br />2. <br />J.. <br />Uj <br />4. <br />14. Special Handling Instructions and Additional Information <br />15. OtNERATOR'SIOFFEROR'S.CERTIFICATION: I hereby declare that the contents ;8%.corisignrent arefully andaccurately described above by thie proper shipping name, and <br />are classified, packaged, <br />marked and labeled/placarded, and are in all.respects in proper condition for transR ce ding to applicable international and national governmental regulations. It export shipment and I am the <br />. <br />Primary <br />Ep9der, 1.6ervy that the contents of this consignment conform to the terms of the2edZAAcknowledgment of Consent. <br />1 certify that the waste minimization statement idenlified in 40 CFR 262.27(a) (if I.amilarge clua0tygenerator) or (b) (it I am a small quantity generator) is true. <br />5gi3eFaWs1Offeror`s PrintdiTyp!,a- —7-15nature <br />on <br />Day Year <br />�4 <br />16. InlemationA Shipments <br />E] Import to U.S. 7" El Export fmm�U.S. Port of entry/exit <br />Transporter signature (for exports only): = Dale leaving U.S.: <br />LU <br />17. Transporter Acknowledgment of Receipt of Materials Gi <br />*nsportarr I Printed/Typed Name. \Noniture <br />Month <br />Da� Year <br />0 <br />JZ <br />M <br />Transporter 2 Printed/Typed Name Signature <br />Month <br />Day Year <br />< <br />18- Discrepancy <br />18a. DLTepancy Indication Space _E1 Quantity.-,,. El EResidue <br />Type Partial Rejection <br />Full <br />Rejection <br />Manifest Reference Number: <br />18b. AJlerqak Facility (or Generator) U.S. 5FIXII) Number <br />Facility`sfhone: Oar <br />_18c. signature of Aiternale Facility (or Generator) <br />Month <br />Day. Year <br />Z <br />19. H Waste ReKQaWgignSnt Melhod.Codes Ci.a, codes fcrfiizaicicu�� le treatment, disposal, and recycling systems) <br />LLJ <br />2.4. <br />1 <br />3. <br />20. Designated Facility Own 1r.or Operator,&Afic .on of receipt of hazardous materials covered by the manifest ex n' !e18a <br />except as, � <br />Ll <br />:FrintediTyped Ipme <br />Month <br />P" <br />D <br />4-, <br />tvA "n -n utuu-a lKev. j-uo)• f:revious editions are qcisoiete. 1, <br />X: DESIGNATED FACILITY TO GENERATOR <br />I-IAm hA5 nhe -am4maif" pni-PiT.'s hT mm?l W1 ;-,0eA,;2 AA� risco w1attyr M-SN-oi, <br />