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<br />DESIbNATE1f FACILITY TO GENERATOR
<br />UNIFORM HAZARDOUS
<br />1, Generator ID Number Page 1 of
<br />3. Emergency Response Phone
<br />4. Manifest Tracking Number V V VJJ
<br />WASTE MANIFEST
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<br />5. Generators Name and Mailing Address "" Generator's Site Address (If different than mailing address)
<br />'P'F,;/ � Wf J 'TPAV i, PITA A f Rf�,F, V MARJTN#'F ' 'i _100 f ri K -R T
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<br />Generators Phone: C7'T ; SM,-'! - R
<br />6. Transporter 1 Company Name VIC
<br />U.S. EPA ID Number
<br />3i,TFi� 3 A HAZARFX'%;113 1;r?.R T m•, 0100VII{ ..Rill)(,::€i--x023
<br />7. Transporter 2 Company Name EPA ID Number
<br />8. Designated Fadilty Name and Site Address U.S: EPA ID Number
<br />Facll s Phone: . 1 0-5: 7- 7 i 00 1 r A, T 0 8 0 0 n .3 5
<br />9,
<br />91b. U.S DOT Desaiption (including Proper Shipping Name, Hazard Class, ID Number,
<br />10. C0ntainers11.
<br />Total
<br />12. Unit
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<br />and Packing Group (if any))
<br />Quantity
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<br />13. Waste Codes
<br />No.
<br />Type
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<br />THIS WASTE STREAM HAS BEEN QUALIFIED
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<br />FOR R CfC1JNGar„ !FATN1r1N'TS AT [HE
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<br />3. Ckelt,l`{i1 :1 ; ih.�.;". Li 11 <:'i1 SLt! !IN ffUNIFIT8111,
<br />nlr., •11 r, zpor. �.tfr,-./rd( NECESSARY
<br />THE CESSARY
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<br />-111 , St7C YO'r"WA TE S T REAM AS
<br />ITSTOR-111,21
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<br />4. QUALIFIED. OUR EPA NUMBER IS CAT080013352
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<br />-14. Special HaMfinngg instructions apdAddh !oM.infomtation <T �tt�
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<br />t "._� �.rp :"�a l e�-i`t �.S t) 1 f'.� �,i r'� l! iti .� ,.�.,Y .^}. R.. .AJ; Y"^ APO Ti\J�`{ RTA"' �1-( T t l"S r�l.'r\Rv�4P i i'S,S+ffjt )ii
<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 classed, packaged,
<br />marked and labeledfplacarded, 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 EPA Acknowledgment of Consent.
<br />I certify, that the waste minimization statement identified in 40 CFR 262.27(a) (d I am a large quantity generator) or (b) (if I am a small qua nlity_generator) is true.
<br />Generlors 0fferp s P inted/Typpd NameJ ynature Month Day Year
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<br />16. International Shipments - -
<br />❑ Import to U.S. ❑ Exportfrom U.S. ,_,✓ Pat of entrylexit:
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<br />Transporter signature (for exports only): Date leaving U.S.:
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<br />Transporter Acknowledgment of Receipt of Materials
<br />Trranrsporter}P nted/Typedamer Signature F`d :'. �' _ Month Day Year
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<br />Transporter rintedlTypedName Signature Month Day Year
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<br />18, Discrepancy
<br />I aa. Discrepancy Indication Space Quantity❑ T pe ElResidue li ElPartialRejection ElFull Rejection
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<br />�r^nCr ;iln!i nf�a•t}j�17 Mani iReferenceNumber:
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<br />18b. Alternate Facility (or Generator)
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<br />Fadlif)ts Phone:
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<br />18c. Signature ofAftemateFacility (or Generator)
<br />Month Day Year
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<br />19. Hazardous Waste Report Management Method Codes (.e.. codes for hazardous waste treatment, disposal, and recycling systems)
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<br />2.
<br />3.
<br />4.
<br />20. Designated Facility Owner or Opera! r. Certification of receipt of hazardous materials covered by the manifest except as nd _in Item 18a
<br />P.rinted/T Name _ Signature --� z^ - .. Moo 4ay , Year
<br />tNA I-orm b/UU-!1(Kev. ;1-Ub) Nrevious editions are obsolete. r
<br />DESIbNATE1f FACILITY TO GENERATOR
<br />
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