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Please print or type. (Form designed for use on elite (11 2-pilch) typewriter.) <br />iu�iu�iMeiu�N�unm <br />0 0 6 1 3 6 9 2 3 5 K S <br />Fnrm Annrovpd OMA Mn 9�50.nnq9 <br />UNIFORM HAZARDOUS <br />1. Generator 10 Number <br />2. Page <br />E cy �!g7i Ph <br />Manife3tTracking Number <br />fI <br />WASTE MANIFEST <br />1 <br />f`*006136923 SKS <br />5. Generator's Name and Mailing Address Generator's Site Address (if different than mailing address) <br />Generators Phone: <br />6. TrU.S. EPA ID Number <br />7. Transporter 2 Company Name U.S. EPA 10 Number <br />8. Designated Facility Name and Site Address A14 U.S. EPA ID Number <br />t <br />f4p-rj.i,- <br />.0 lT 130) .' <br />NTI. <br />Facilli 4 Phone., <br />ga. <br />9b. U.S. DOT Description (including Proper Shipping Name, Hazard Gass, ID Number, <br />0. a'111114 ers <br />11. Total <br />12. Unit <br />HM <br />and Paldng Group (if any)) <br />Quaotily <br />WLNoI. <br />13. Waste Coces <br />No, <br />Type <br />Tul. <br />960 <br />1; 11 ®r '.3, 3, rt[-:; T I -Y <br />Cr <br />D. <br />LLI2 <br />UI <br />. <br />4. <br />74. Special Hardiing instructions and Additional Information 1s-0 I rd -lis Ad, 3 <br />". HR 1, `rOIE'k - , <br />ENCY <br />SEE <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, parka d, <br />marked and labelediplacarded 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 <br />F%pDrier. I certify that the contents of this consignment conic to the temirs of the attached EPA Acknowedgme t of Consent <br />I certify that the waste rninim4ation statement identified in 40 CPR 262.27(a) (ifI am.a LiW quantity generator) or (b) (VI - --ri-Ilquantity generator) 2 true. <br />G lor`s10ff&r&s Printed/Typed Name Signa ' ture l"onlil Da • Ya r <br />16.1nierriational Shipments El import to U.S. Export firo.UYV Port of <br />'g <br />Transporter signature (for exports only): Data lea U.S.: <br />17. Trans der Acknowledgmentof Receipt o(Materials <br />r r I PMtecVTy* m a Signature Month Dail` Y, <br />f retl ra <br />C' <br />d I <br />CL. <br />cr <br />21 <br />Trans - 2 Pr tedfTyped. Name Signature Month Day Year <br />18. Discrepancy <br />18a. Discrepancy Indication St El Quantity -Type Ll Residue ❑ Partial Rejection E11FAIRefection <br />Manifest Reference Number. <br />l8b.Aftemate Facility (orGenerator), U.S. EPA ID Numbor <br />LL: <br />Fadivs Phone: <br />18c. Signature of Alternate Facility (or Generator)T <br />lonU Day Yeer <br />Cr19. <br />Hazardous Waste Report Management Method Codes (i.e., codes I`orhazafd6us waste treatment, disposal, and recycling systems) <br />LL; <br />- <br />1.3. <br />HIM <br />4. <br />20. Designated Facility Owner Qr Operator Ci(fification of receipt 6i hazardous materials covered by the manifest except as noted In Item 18a <br />Printedrrypej Ne Signalu Year <br />F -PA Formfop-&(Rey. 3061-111FAIdNATED. FAC I Lrry TO-DESTI NATION STAT RMORED) <br />