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<br />r=m rurm oluu-4/ lmev. ,coo) rrevious eamons are oosolete. DESIGNATED FACILITY TO GENERATOR
<br />UNIFORM HAZARDOUS
<br />Generator ID Number
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<br />3. Emergency Response Phone
<br />4Manifest Trackingg�N•umber
<br />WASTE MANIFEST
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<br />6. 1 ranspporter 1 Company Name U.S. EPA ID Number
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<br />7. Transporter 2 Company Name U.S. EPA ID Number
<br />8. Designated Facility Name and Site Address U.S. EPA ID Number
<br />Facility's Phone: ' 562'+ 4 32•-5445:
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<br />91b. U.S. DOT Description (including Proper Shipping Name, Hazard Class, ID Number,
<br />10. Containers
<br />11. Total
<br />12. Unit
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<br />and Packing Group ('d any))
<br />Quantity
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<br />13. Waste Codes
<br />No.
<br />Type
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<br />3. REFtFNCT
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<br />'r`CORDtNCd"y 3'T a? REF• REN( WAST$ '`IYTN H.SS AI -1 OF AFPf_rCABLP
<br />ANG All. 2,1E WAS"i"E
<br />NECESSARY
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<br />F{AS BEEN FiA
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<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 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 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) (ifd am a small quantity generator) Is true.
<br />Gen torslOfferorsPrintedlTypedNamegnature Month DayYear
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<br />151 International Shipments❑
<br />Import to U.S. ❑Export from U.S. Port of entrylexit:
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<br />Transporter signature (for exports only): s Date leaving U.S.:
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<br />17. TransporlerAcknowledgment of Receipt of Materials
<br />Transporter)Ennted/Typed Name Signature y---- Month Day ' Year
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<br />Transporter 2 Printed7Typed Name Signatures Month Day Year
<br />18. Discrepancy
<br />18a. Discrepancy Indication Space ', '
<br />[ t ❑Quantity �. 9 ❑ Types ❑Residue ❑ PaNal Rejection ❑ Full Rejection
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<br />Manifest Reference Number:
<br />18b. Alternate Facility (or Generator) U.S. EPA ID Number
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<br />Facility's Phone:
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<br />18c. Signature ofAllemate Facility (or Generator)
<br />Month Day Year
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<br />19. Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste treatment, disposal, and recycling systems)LU
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<br />20. Designated Facility Owner or Operator, Certification of receipt of hazardous materials covered by the manifest 1kcept as noted in Item 18a
<br />PrintedlTyped Name j Sign t � i, Month Day, Year
<br />r=m rurm oluu-4/ lmev. ,coo) rrevious eamons are oosolete. DESIGNATED FACILITY TO GENERATOR
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