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°t d:,,K E.t;, P ,.. ; <br /> Please print type (Form designed for use oti,elite(12-pitch)typewriter) Form ApproV,+ <br /> QRM HAZARDOUS, 1•Generator ID Number 2.Pa 1 of 3.Em gn r� <br /> WA T MARIFEST �)� �,�> s <br /> 9 �Ry e� set 4.Manifest Tracidng Number <br /> 5 GenerBfors Name and Mailing Address Generator's SiteAddress(if different than mailing address) <br /> rt Sats 8d> t 8At fn <br /> � 6 We anfo d Rdt t ti ����� hell-fry 18501 tatlfort� RdJOACY , <br /> t t s�3 tfi safety Ban Y`f <br /> Generators Phone: i AM393 4 6. TRACY ' <br /> t 1 <br /> T o eITIF <br /> tri F; I NIC U.S.EPA ID Number <br /> TXR <br /> 7.Transporter2 Company Name U.S.EPA ID Number <br /> 8.Designated Facility Name and Site Address r� ,, �, <br /> 8fY f Y t s EF'( OF Q.QL I F U.S.EPA ID Number <br /> �f (� R <br /> d Cts 9kr -i I <br /> Farality'sPhone: <br /> gam, 9b.U.S.DOT Description(including Prpper Shipping tf�rti6,Hazard Class,ID Number, <br /> Hhj and Packing Group(if any)) 11 Rotat: ' 1-Unit <br /> N 10.Containers o. Type " Quantity Wt.Nol. 13.Waste Codes <br /> OI �. <br /> o g <br /> w <br /> Z 21: <br /> Ujf <br /> 4.s <br /> I , <br /> 14.Special Handling Instructions and Additional Information € <br /> ADM 198 <br /> i= VR "MER E�NIIr ' t i1�sy 41 �yyf,r�� r 6 �,761%_�( ��&;4� `�tr� 1), g� CARRIERS <br /> ��3 r}i9 # �p Y� tak t g� ,} <br /> &`# S t, 4 f" "4Ff'.70 EIV €Jj. E1 3RD#- RE: j L.st�s�Ylc.9,? .�..2 .- S.�€'adET4ISCs`b t e,� f�r�.B.:r �r{sY"�S E <br /> 15. GENERATOR'S/OFFEROR$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.'If export shipment and I am the Primary <br /> Expolter i cedtty that the contents of this consignment conform to the terms of the attached EPAAcknowledgment of Conse <br /> I certify,that the waste minimization statement identified in 40 CFR 262.27(x)(if I am a targe quantity generator)or(b)(if I ar(�a small quantity generator)is true. <br /> Generators/Offerors Printed/Typed Name Signature' <br /> Month Day <br /> A41, <br /> w _ <br /> —J 16.Inle ational Shipments <br /> z' ❑Import to U.S. Export from U.S. `a- Port ofentry/exit: <br /> Transporter signature(for exports only): Date leaving U.S.: <br /> 17.TransporterAcknowiedgment of Receipt of Materials <br /> anspoder1 Printed/Typed Nem nature <br /> u0.j f =M � Month Day Year <br /> ZQ Transport Printed/Typed Name <br /> Signature Month . Day Year <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space <br /> Quantity Type ❑Residue $ ❑Partial Rejection Full Rejection " <br /> 18b. Manifest Reference Number: <br /> Alternate Facility(or Generator) ` <br /> U.S.EPA ID Number <br /> V <br /> LL Facility's Phone: <br /> LU 18c.Signature of Alternate Facility(or Generator) <br /> ZMonth Day Year <br /> w19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> 1 �' " 2. 9 <br /> { 4. <br /> r <br /> 20.Designated Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a <br /> Printedlfyped Name "f " <br /> ' <br /> ' 1 Signature PI <br /> , ,pr , Mgnth Day Ye <br /> E`r e ,' o r <br /> EPA o m 7 0.22 R 0 Previous edifions`are obssolete. �u <br /> F t ( y ) DESIGNATED FACILITYTO GENERA OR <br /> f r <br />