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Please orint or Woe. (Form desioned for use on elite (12-nilch) tvnewriter.l`t "` ! r'# �' SCM1.1 1-0/10t20G-,, e-,, .d nnea nk )ncn M10 <br />crHrorm.ocuq;nelr¢gyfgfjr•FYI§_ and will accel>tj5yjyjft)pfftC.. DESIGNATED FACILITY TO GENERATOR <br />UNIFORM HAZARDOUS <br />1. Generator ID Number <br />2. Page 1 of <br />3. Emergency Response Phone 4. <br />Manifest Tracking Number <br />WASTE MANIFEST <br />(': ii ).. {� tit) 'r 7 4 : , <br />t �ti�'�k,(.<<..- e .d., <br />FSE <br />5. Generator's Name ailing Address ! Generator's Site Address (if different than mailing address) <br />}'FtBt15t)il (1 <br />Al <br />r*ai'i C*i,4 of Stiiatnlr f xpy <br />11(1010". CA 0200,10 <br />Generators Phone: <br />6. Transporter 1 Company Name U.S. EPA ID Number <br />Ch- all Hi.iIh ors C iviralimetital fi+MceS, It}D, 2 fl +9 15 V <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 />ailive Rcirjurcr.-Reeayefiv Inc. <br />Grove Avarlu e ;* t. ._ <br />+=in6nnafi. Off 49232 <br />Facility's Phone: <br />ga. <br />9b. U.S. DOT Description (including Proper Shipping Name, Hazard Class, ID Number, I <br />'10, Containers, <br />11. Total <br />12. Unit <br />HIM <br />and Packing Group (if any)) <br />Quantity <br />Wt.Nol. <br />13. Waste Codes <br />too.,. <br />Type <br />��1i�s�a:dr�I�altac� ct; <br />Iii l <br />, <br />t�Y.t1CdibCHtC�TdICltC:�C)"•rft.k�1R+!I ysGIE t Ka i4 <br />LU <br />2. i <br />w <br />3. <br />4. <br />1�.SpecialF(a dlip��19tructionsasndjdditionalInformation <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 intemational and national governmental 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''ssmall quantity generator) is We. <br />GeneratoeslOfferoes PrintedlTyped Name signature Month Day Year <br />-J <br />Z <br />16. International Shipments <br />❑ Import to U.S. ❑ Export from U.. Port of entryle it: <br />Transporter signature for exports only): Date leavin U.S.: <br />W <br />17. TransporterAcknowledgmentof Receipt of Materials <br />Transporter 1 Pnnledfryped Name Signature Month Day Year <br />off. <br />/� ' :� <br />Z <br />Transporter 2 Printedf yped Name Signadee /l Month uay Year <br />_ <br />18. Discrepancy <br />l8a. Discrepancy Indication Space <br />Quantity ❑Type ❑Residue El Partial Rejection ❑Full Rejection <br />Manifest Reference Number: <br />18b. Alternate Facility (or Generator) U.S. EPA ID Number <br />V <br />Facility's Phone: <br />JIM <br />18c. Signature of Alternate Facility (or Generator) Monih 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 />UJ <br />1• <br />3. <br />4. <br />20. Designated Facility Owner or Operator: Certificalioq of receipt of hazardous materials covered by the manifest except as noted in Item 18a <br />Printed/Typed Np" <br />�.� Sig7alure //_ Mone, DayYear <br />iat <br />crHrorm.ocuq;nelr¢gyfgfjr•FYI§_ and will accel>tj5yjyjft)pfftC.. DESIGNATED FACILITY TO GENERATOR <br />