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Please Drint or Me. (Farm de.qinnp.d fnr use nn Min 11 7.Allrh) funAwritar I <br />IIIflIII�I�IMV�NI�lllinl <br />0 0 6 1 3 6 9 2 3 S K S <br />UNIFORM HAZARDOUS 1 1. Generator ID Number <br />2. Peke <br />Er�jqalqcy Roponsq pl�cino <br />_4M.. Vast Tracking 1, <br />WASTE MANIFEST <br />1006136923 <br />SKS <br />5. Generators Name and Mailing Address Generaloes Site Address IN different than mailing address) <br />P <br />Generators Phone: <br />6.TW *1\,! �, ". U.S. EPA ID Number <br />7. Transporter 2 Company Name U.S. EPA 10 Number <br />8. Designated Facility Name and Site Address U.S. EPA 11) Number <br />-N W11 Al <br />"M . 91 V7 <br />Faciri es Phone: <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 />HIM <br />and Packing Group (it any)) <br />Quantity <br />Wtivol. <br />3. Waste Codes <br />1140'' <br />0M <br />960 <br />51 <br />0 3, rq fF <br />U, <br />2. <br />M_ <br />444— <br />7 4 0 i2l, I" <br />T4, Special Handling Instructions and Additional Information y r<i3 <br />fz P8 <br />06'�-Pjf`-Y 44 - -P.40 43, 17�- F-.! - <br />4 H - '%Vr <br />115.. GENERATOR'SIOFFEROFrSCERTFICATION: I hereby declare thaf the contents ofthis consignment are fully and accurately described above by the proper shipping name, and are classified, packs ed, <br />marked and laboled(placarded, and are in all respects in proper condiflowfor transpod according to applicable international and national governmental regulations. It export shipment and I am the Primary <br />Exporter, I cerfily that the contents of ibis consignment conform to the terms of the attached EPAAcknoWedgment of Consent <br />I certify that the waste minimization statement Identified in 40 CFR 26227(a) (f I am a large quantity generator) or (b) (Ifl a sural quantity generator) is true. <br />Da Ye <br />Ge Pdi drryped Name Signahwe Year <br />V <br />/j0,1rA"6-_ (X&CA_TIIU- - <br />_ <br />16. 'Intemational Shipments <br />El impd to U.S. ElExpod from Port Of xi <br />Transporter signature (for exports only): Date leaU.S.: <br />17. TSWrter AckrimMedg ment of Receipt of Materials <br />CrT�or <br />1 Print me Signature Month Day- -Y <br />C <br />r.L <br />< <br />Tra 2 Pr tedfTypoIName SignatureMonth Day Year <br />i <br />I I <br />4 <br />tmo <br />Jay '00e_1 CA <br />18. Discrepancy :z - <br />18a. Discrepancy IndIcation-Space —1 Full R <br />1:1 Quantity L1 Type ❑DR.Idue ElPartial Rejection Rejection <br />Manifest Reference Number. <br />18b.AllemateFacilty(or Gen6rator).. U.S. EPA ID Number <br />LL: <br />Faaliys Phone: <br />r-, <br />18c. Signature ofAltemale FacAity (or Generator) Month Day Year <br />I Hazardous Waste Report Management Method Codes (i.e., codes t6r hazardous waste treatment, disposal, and recycling systems) <br />ct <br />1.H aq6 <br />3. <br />4. <br />20. Designated Facility Qwner�.qr Operator. of receipt 81, hazardou's materials covered by the manbst except as noted In Item 18a <br />Pd*drFyM Na SigraW Day .-Year <br />17TA <br />FPJM470_0:2MPY,1- E!reL .-gESIdNATEDFACILITYTo-nE9TINATION STATE R#nl <br />