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Please print or type. (Form designed for use on elite (12 -pitch) lvpewriteciir) i ob ift'i 95.1. 0 itl:' P11W 4.O 4.0, 2 03.7 G- A---1 MAO klu Inch nnon <br />tNAI-orm 5700122 (Rk, &.06) : Frevilous.elaitions areolsolew, J,w and v)jli 0i: <br />GENERATOR'S INITIAL COPY <br />- <br />UNIFORM HAZARDOUS <br />1. Generator ID Number <br />2. Page 1 of <br />3. Emergency Response Phone <br />1111" --- <br />4. Manifest Tracking Number <br />WASTE MANIFEST <br />4) C? t) '# •`; : '.t �! <br />d,-;(�{tj �(la ; <br />FLE <br />5. Generator's Name aVd�{ailing Address Generators Site Address (if different than mailing address) <br />i1w.:U11 o. D. <br />r;10 Volt (it tvi;l Empy <br />c/1fVS1: <br />-1011141- 1. (*A 9il '' , ; <br />Generator's Phone: <br />6. Transporter 1 Company Name U.S. EPA ID Number <br />ii?Hit :I<lY)Ni: [ itVitQlltlik+iltiAt�it+t'�/SG'kLS,�111' 1,� ,F+ ("d i. f �i i! .e3 iM k'� f1 <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 />( i filtiAb 1 okle Ht:m(it41to" Rvir"cwtrlV 11, <br />fl.ytlhl! Guli+le Avettifo <br />wi Off <br />Facility's Phone: <br />98. <br />9b. U.S. DOT Description (including Proper Shipping Name, Hazard Class, ID Number, <br />10. Conla!ners <br />it. Total <br />12. Unit <br />HM <br />and Packing Group (if any)) <br />Quantity <br />Wt.Nol. <br />73. Waste Codes <br />No. <br />Type <br />1.1IN13 "44,'.it?1.1i.)! (`0l1) 119i' t3f242f�51Y1 !.!(��Itl�, N.0 <br />of <br />(1; (At.liFsi_) <br />Z <br />2. <br />w <br />0 <br />3. <br />4. <br />14. Special Handligg I(,struclions and Additional Information ("ll +r hill": <br />15. GENERATOR'SfOFFEROR'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 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 />Exporter, t certify that the contents of this consignment conform to the terms of the attached EPAAcknowledgment 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 eror's PrintedlTyped Name Signature Month D ay ear <br />A .i <br />16. International Shipments <br />El Import U.S. ❑Export <br />to from U.S. Port of entry/exit: <br />- <br />Transporter signature for exports only): Date leaving U.S.: <br />IX W <br />17. Transporter Acknowledgment of Receipt of Materials <br />ii <br />Transporter 1 Printed/Typed Name Signature MonthYear <br />a <br />zTransporter <br />2 Printed/typed Name Signature Monuh Day Year <br />f- <br />18. Discrepancy <br />18a. Discrepancy Indication Space Ej Quantity El Type ❑Residue ❑Partial Rejection ❑ Full ReIsicticin <br />Manifest Reference Number: <br />18b. Alternate Facility (or Generator) U.S. EPA ID Number <br />J <br />U <br />a <br />LL <br />Facility's Phone: <br />N18c. <br />Signature ofAlternale Facility (or Generator) Month Day Year <br />Q <br />Z <br />0 <br />rn <br />19. Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste treatment, disposal, and recycling systems) <br />0 <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 !lem 18a <br />Printed/Typed Name Signature Month Day Year <br />tNAI-orm 5700122 (Rk, &.06) : Frevilous.elaitions areolsolew, J,w and v)jli 0i: <br />GENERATOR'S INITIAL COPY <br />