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T Lt S ( 1JtJ63. 12 j7 Please print or type.(Form designed for use on elite(12-pitch)typewriter.) F-1A°"��-' A??:C"2"- ' '- ?�T'-°2 Form Approved.OMB No.2050-0039 UNIFORM HAZARDOUS 1.Generator ID Number 2.Page 1 of 3.Emergency Response Phone 4.Manifest Tracking Number WASTE MANIFEST a - — 1 2 ,4°3-2. . 001091566 FLE 5.Generator's Name and Mailing Address Generators Site Address(if different than mailing address) 47:' CA 2Z 2Z 7 Generators Phone: 6.Transporter 1 Company Name U.S.EPA ID Number IV A D Z 3 9 3 2 2 2 5 3 7.Transporter 2 Company Name U.S.EPA ID Number 8. esi nated Facility.Name and.S!tte Address, U.S.EPA ID Number ��,�a s tea^�,se '?tic' aerr�essa Road A ^ 0 5 9 4 9 4 3 ' 0 Facility's Phone:' ^�� =2 ga 91b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit HM and Packing Group(d any)) No. Type Quantity Wt.Nol. 13.Waste Codes 11�y195rv�rtSTcA=RO�OL ,i.1,;')CZ.E IP�PT=D QUA,,.' I)OC7 343 o K 0 U I D F 0 0 0 0 4 P W2'_ _ 'IJk�..rAHB� .d:.r:w:, V v.J., -TPtV�u�,� �331' 343 co X il'A?THA,Al-C&HOi_OE1�1ATURED).3,FG ii C G I C F 3 0 0 4 0 P 3,•v,, ''�O S A -2 r-_� 0 342 • ! 'l/'�f�('+✓✓u .0 utcurUS,�J'i l�ifti' u� �riGEiVTSI:i�fA 1 Gi�E; O:�c 3 G . G F G G 4 3 P 4. 14.Special Handling Instructions and Additional Information ... LCCRQ LC'::E�? LC R;' ' V. 2. LCCAC LP97?40E7-02'.' 15. GENERATOR'S/OFFEROR'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, 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 Exporter,I certify that the contents of this consignment conform to the terms of the attached EPA Acknowledgment of Consent. I certify that the waste minimization statement identified in 40 CFR 262.27(a)(if 1 am a large quantity generator)or(b)(if I am a small quantity generator)is true. eneratOfferors Pnniedrfyped Name igna re Month Day Year J 16.Intemational Shipments F ❑Import to U.S. El Export from U.S. Port of /exit: Trans orter signature for exports only): Date leaving U.S.: Y 17,Transporter Acknowledgment of Receipt of Materials � Transporter 1 Printed/Typed Name Signature olnth ay Year rl CL Z�: C Transporter 2 PnntedrTyped Name Signature Month Uay Year F- 18.Discrepancy 18a.Discrepancy Indication Space ❑ Quantity ❑Type ❑Residue ❑Partial Rejection ❑Full Rejection Manifest Reference Number. 18b.Altemate Facility(or Generator) U.S.EPA ID Number J U Q u Facility's Phone: LU 18c.Signature of Altemate Facility(or Generator) Month Day Year Q Z t7 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) LLI N J / ` 1 fhy 2 3 [ [ 4. 20.Designated Facility Owner or Operator:Certification f receipt of hazardous materials covered by the manifest ex pt t noted in Item 18a P' ped Name Signature Mon Day Year of F.PA Form 870x22(Rev_3-0q) Previous editions are obsdeteFACIUTY q"NAtION STATE . _.... . ,_ ,b YSP . (IF REQUIRED)G � O Aqncx; 10349.0951 -