|
3� (j 1� 7jGj
<br /> ,, � .-
<br /> 9: }
<br /> ;r: Ple2se print or type.
<br /> F-1 UNIFORM HAZARDOUS 1.GeoeralorlDNumber Fo ., d.OMB No.2050-0039
<br /> WASTE MANIFEST 1s1i9€r'r''" , ? 2 Ppge�Fof Y3 Eme�ggo� Ris o eP. on Ipf 4 Mani fest TRIkin "J;<•' t
<br /> 5.Generator's Nameand.Maihng Address 4 +1 Y1 y � SKS
<br /> a<a �v':8rt BEzr,: , i LEq Generators Sde Address pf ditrerem than malllinng�adding
<br /> z:5 117"i^ 6 I•f „Y.., SJ 4� pn t 17J
<br /> f P Y
<br /> Generators Phone: -
<br /> 6.Tra0s�Pra.Cpmpp�ly
<br /> � '" E`` ILS.EPA ID Number
<br /> 7.Transporter 2 Company Name -
<br /> ti ' rtipj ,q:-4vr 41#�_� ^,l frfia"tC1 <'Si �4',}7 as vq t USp ID Number
<br /> 0.Eeslgnated Facility Name and SiieAddmas
<br /> ,-� r1{•a °3(,"J�8`, :U[ P 1F3 .._ PAID Number
<br /> :ir"-1t; tL er � �r i•P
<br /> 40
<br /> Facility's Phone:
<br /> 9, go.U.S.DOT Desenpban(including Proper Shipping Name,Hazard Glass,ID Number,
<br /> HM and Packing Group(if any)) 10,Containers 11.Total 12.Unit
<br /> of 1 No. Type Quantity Wt Nol
<br /> I 13.Waste Codes
<br /> h f, c� r,
<br /> tX
<br /> 2. f
<br /> t1J
<br /> C9
<br /> k
<br /> i
<br /> -- 14.Special Handling Instructions and Additional Information
<br /> i ^q�EArn f
<br /> " -... 3 •ti=�: t;L;7t1 e �..... t_
<br /> NAL
<br /> :)-at €i r}.Y . 51 cr1 .
<br /> Uv .{r..t y ,, ..1 3 i t<' ,ryr gl f t as Az` a {1i,
<br /> }as r� •2f.E d ...i'�s Prd 3Y..C,Ute' ,rt r :7 i ' r, s a
<br /> 15 GENERATOR'SfOPFEROR'S C and
<br /> TIFImaC all res thereby declare that the contents of this consignmantam fully and accurately descdbad shove.—OY l,R Proper er shipping name,and are classified,packaged,
<br /> marked and labeledaplacarded,and are In all respects in proper condition for transport according to applicable international and national govemmentel regulations,If export shipment and i am lite Pdmary
<br /> Exporter.I teddy That the contents of this consignment conform to the terms of the attached EPA Acknowledgment of Consent
<br /> I teddy that the waste mtmmization stalamenl identified in 40 CFR 252.27(a)(if I em a large quantity generator)or(b)(ifI am a
<br /> Gsmall uaplity generator)is true.
<br /> eneratofAtpRerofg'pnNeRRRad Name' Signelurer ar r
<br /> ,(4 r, „t Month Day Year
<br /> 18 International Shipments - r ^✓(r2•.._ ,'❑ r&Import to U.S. ❑Export from U.S. Pad of entry/exii
<br /> Transporter signature(tor exports only)_,
<br /> Oats leaving U.S, .'� ,n c ,
<br /> 1Z TransILIpoderArknawledgreen[of Receipt of Materials �t
<br /> Tru"sliprler 1 Pnn1eN't}ppd Name
<br /> i s
<br /> ypyn a `Year;
<br /> Transporlae2 PnbtedtN
<br /> TypaA ame
<br /> ,c 5igr urea
<br /> Month Pa Year
<br /> /✓
<br /> 13.Discrepancy
<br /> 'IUs.Discrepancy Indication$pace.
<br /> QaamltY ❑Type ❑Residuo 'P"
<br /> Partial Rejection Full Refection
<br /> �L7,F1Pir.Alternate Facility(or Generator) Manifest Reference Number
<br /> ):? U.S.EPq ID Numher
<br /> t i�A Fagltrys Phone:
<br /> L:-11TS:l1nrgkTre ofAliernaleFaaUfy(orMomh Day YAarous Waste Report Management Maniac!Codes(Le.,codas for hazardous waste treatment,disposal,and recycling systems)
<br /> cy
<br /> 4
<br /> � .fr✓ Y
<br /> 20.Designated Facility Owneror 0 emtor Ceyiificabon of receipt orhazardous matenals coveted by the manifest excep as nIXed in Itea(;1✓ta'
<br /> PdnledlTyped Nam� r ;r. �
<br /> s �„ % Signature;' �!� r Month Day` .Year r
<br /> Cr
<br /> Coen t}7t{Q 2�(Rev,72e17f �gvlous edltibns al'e'olasalete, ' - -
<br /> �
<br />
|