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Please print or type. (Form designed for use on elite (12 -pitch) typewriter.)')) s'I!? ri!'ft 9'IpiT !4�;'' FIt 7 Fnrm Annrnvari (ItAR Nn gnrn_nmo <br />A <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 />;l ; + .; <br />t, ,� r*. L FL E <br />5. Generator's Name and Mailing Address Generator's Site Address (if different than mailing address) <br />r. ,,• i°.` }'til a 1.%r •;tali i.,i\i.irri i. za.iy <br />Generators Phone: <br />6. Transporter 1 Company Name U.S. EPA ID Number <br />itY!'1tttltf YYYHrt;rt ";r'. �r='f��. �t6,• <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 />1.4oYyi','.:Y1r4Ytrt,+ 4-- 4 4 4 ., :a. (? <br />Facility's Phone: <br />ga <br />91b. U.S. DOT Description (including Proper Shipping Name, Ilazard Class, ID Number, <br />10. Containers <br />11, Total <br />12. Unit <br />HM <br />and Packing Group (if any)) <br />Quantity <br />WtNol. <br />13. Waste Codes <br />No. <br />Type <br />1 :.�26iY,,uilfp i C. '-��TlRL�tJi���.Tvf;A{i�1, �'i�rJ�f-, {F`a Vl•��9l�rtit' <br />t <br />o <br />V4.0-9,", r�t)14�tn F►'� 1}lzOui�fN lFr.)t:+��'>=,lt!nn tivJ4irlx�r►E:}, >3 r�tl <br />�J �'.' <br />e •��' <br />LU <br />2. <br />to <br />3. <br />4. <br />I <br />14. Special Handling Instructions and Additional Information <br />15. GENERATOR'S10FFEROR'S CERTIFICATION: I hereby declare [fiat [tie 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 governmental regulations. If export shipment and I am the Primary <br />Expoder, I certify that the contents of this consignment conform to the terrns of the attached EPAAcknowledgmenl 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 />Generators/Offerors Printed/Typed Name bignature Month ay ear <br />�J <br />16. International Shipments <br />❑ Import to U.S. ElExport <br />F- <br />- <br />from U.S. Pod ofentry/exit: <br />Transporter signature (for exports only): Date leaving U.S.: <br />Of W <br />17. TransporlerAcknowledgment of Receipt of Materials <br />Transporter 1 PrinledRyped Name Signature Month Day Year <br />Cl - <br />Transporter 2 Printed/Typed Name Signature Month Day Year <br />H <br />18. Discrepancy <br />18a. Discrepancy Indication Space ❑ Quantil y ❑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 />Facility's Phone: <br />W <br />18c. Signature of Alternate Facility (or Generator) Month Day Year <br />Q <br />Z <br />C, <br />19. Hazardous Waste Report Management Method Codes (i.e , codes far hazardous waste treatment, disposal, and recycling systems) <br />0 <br />1. <br />2. <br />1 <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 />PrintedlTypcd Name Signature Month Day Year <br />trH rorm u(y + iii ifi�if s•ub) Previous editions are obsolete. • , tnr and will astept tf,e W,liste the 4er1p1 atas is StNpjYiq{;. GENERATOR'S INITIAL COPY <br />