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Please nrinl nr Ivna (Fnrm riesinnprf for usa nn alila 119_nilrhl hrno,urilnr 1 • • �! _s,..,, �:!$�A t�• #�;5 .,;(' VIP?/ '(,(} T :t I <br />�ni vini.y,w-cc,l,�cgf.ruk�/: ;wY u3wl,,Lltyp�lmY(�Y?,yll;,e;t7't5,j ; rld will acce pI-��NG3d'i�°r c€�1� �;nrrtc+rattlr is s(lippirix,. DESIGNATED FACILITY TO GENERATOR <br />UNIFORM.IiAZARDOUS <br />1. Generator ID Number <br />2. Page 1 of <br />3. Emergency Response Phone 4. <br />rr <br />Manifest Tracking Number <br />WASTE MANIFEST <br />F L E <br />5. Generators Name Mailing Address Generator's Site Address (if different than mailing address) <br />is='�t1 Frsit't rif !.'t'irtltia3l; _��i�j. <br />iC§C'1i.(iJRB. Cid, 952030., <br />Generators Phone: # '}n9l 943.9 1 0 <br />6. Transporter 1 ompany ame U.S. EPA ID Number <br />.:' - ' 1.:9}Vii'S1E4i9'i+7tlt�il:jNi�m9rr_$, ii►r;. '..", ;.; ,, <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 />` �lfYlj�CiE(iSrti'3�+PI!iO4ltCL+�i@l=i}'f@bT,r)9'IC. <br />079Svririg' GraaeAvt?nun <br />iiia-inS'9a)1. Off 4921""12 <br />Facility's Phone: M3 131 G13t-5 f U30 <br />ga, <br />9b. U.S. DOT Description (including Proper Shipping Name, Hazard Class, ID Number, <br />10. Containers <br />11. Total <br />12. Unit <br />HM <br />and Packing Group (if any)) <br />Quantity <br />WLNoI. <br />13. Waste Codes <br />No. <br />Type <br />1'M'3244,c��a>�r+ <br />o........ <br />Z <br />2. ,. t <br />0 <br />...... I ..... <br />.... <br />3. <br />4. <br />14. Special Handling Instructions and Additional Information . <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 labeled/placarded, and are in all respects in proper condition for transport according to applicable international and national govemmental 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) (if I am a small quantity generator) is true. <br />Generatoesl0 erors Printed/Typed Name bignature on ay ear <br />p� <br />J <br />F- <br />16. International Shipments <br />❑ Import to U.S. ❑ Export from U.S: ' Port of entrylexit: i <br />Z <br />Transporter signature for exports only): Date leaving U.S.: 7 - <br />LU <br />17. Transporter Acknowledgment of Receipt of Materials <br />I-- <br />Transporter 1 Printed/Typed Name Signature Month Day Year <br />a <br />_ -( <br />�z� <br />Transporter 2 PrintedlTyped Name Signature1 onth Day Year <br />18. Discrepancy <br />18a. Discrepancy Indication Space ❑ Quantity ❑ Type ❑ Residue ❑ Partial Rejection ❑ Full Rejection <br />Manifest Reference Number: <br />18b. Alternate Facility (or Generator) U.S. EPA ID Number <br />J <br />U <br />Q <br />Lr- <br />Facility's Phone: <br />w <br />18c. Signature of Alternate Facility (or Generator) Month Day Year <br />Q <br />Z <br />19. Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste treatment, disposal, and recycling systems) <br />p <br />1.' , .. <br />2. <br />3. <br />4. <br />20. Designated Facility Owner or Operator: Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a <br />ted/TypedNamp ) ? Sgna4ure 14 �. Monlp Da�! year) <br />lr <br />�ni vini.y,w-cc,l,�cgf.ruk�/: ;wY u3wl,,Lltyp�lmY(�Y?,yll;,e;t7't5,j ; rld will acce pI-��NG3d'i�°r c€�1� �;nrrtc+rattlr is s(lippirix,. DESIGNATED FACILITY TO GENERATOR <br />