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70/`7 1 <br />t / rzh� ' 1n Q Fnrm Anoroved- OMB No. 205MO39 <br />EPA form H7DU [[ (rcev, s uo) rrevaus saloons are Obsolete.0_0 9 _ 0 � f' 0 4 : 0 1 R C V DESIGNATED FAGLITY TO GENERATOR STATE (IF REQUIRED) <br />10171.2014 <br />UNIFORM HAZARDOUS' <br />1, Generator ID Number <br />2. Page 1 of3 <br />Emergency Response Phone <br />4. Manifest Tracking Number <br />' 000751503 JJ K <br />WASTE MANIFEST <br />O00 707 e <br />800 - <br />5. Generator's Name and Mailing Address Generator's Site Address (if different than mailing address) _ <br />/0'a""7-7 <br />Sl,& V. /'7 A+a S1� r�� &/ 6 A/, /y11";D S* <br />.Cod,' 64-9`J-:.7'10 6� o�d.' G4 9 s-1 `t <br />Generator'sAone: �O 9 a0 69/ <br />6. Transporter 1 Company Name U.S EPA ID Number <br />-14 C Z--/-7 <br />7. Transporter 2 Company Na&e U.S. EPA ID Number <br />B. Designated Facility Name and Site Address U.S. EPA ID Number <br />a/s* ce.l-ltr.le <br />lacS,�d <br />o9ErAl -c'-, /L 5 ,�. E•9s <br />�h�/i�9E1710U <br />FacilanS ^ ---;7X0 /VU ';g -O 9S <br />ga. <br />9b. U.S. DOT Description (including Proper Shipping Name, Hazard Class. ID Number, <br />10 Containers <br />1. Total <br />12. Unit <br />13. Waste Codes <br />No. <br />Type <br />HM <br />and Packing Group (A any)) <br />Cuantity <br />WtNol <br />1 Ain <br />PG/ E/n2G <br />LU <br />141/11117/3, <br />2 Lv o,,s4c. 4rj ; r c .So l i k, /,-z as <br />C yAr1 , J e , s o J c cA'^N d� yc f e o Y c4 e� 6 . /, G�iv3a <br />C� <br />/ lakd: <br />aZ <br />Gil b <br />3. <br />4. <br />t; <br />14. Special Handling Instructions and Additional Information - <br />fr .3 S 1?3a 9-00 z,a c cyA'Jc �vCo6 1 x30 <br />Ix is` <br />15. GENERATOR'SIOFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accuratety 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 />Exporter, I certify that the contents of this consignment conform to ft 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 a small Cuantiry, generator) is true. <br />Gene es/Offerofs Prnted/Typed NameSI .a Month Day Year <br />166-10407 <br />16.In mat ipments <br />❑ Import to U.S. ❑ Export from U.S. Port of entry/exit: <br />Transporter signature (for exports only): Date leaving U.S.: <br />IX <br />17. Transporter Admawledgment of Receipt of Materials <br />Prnted/Typed Name Sign Month Day Year <br />T sporter 1 u a <br />Z <br />Transporter 2 Pri`ted(Typed Name Signature Month Day Year <br />18. Discrepancy <br />1 Be. Discrepancy Indication S <br />� � Dace ❑ Quantity ❑Type ❑Residue ❑Partial Rejection El Full Resection <br />Manifest Reference Number <br />18b, Alternate Facility (or Generator) U.S. EPA ID Number <br />J <br />V <br />LL <br />Facility's Phone: <br />18c. Signature of Altemate Facility (or Generator) <br />Month Day Year <br />aW <br />Y <br />H19. <br />Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste treatment, aisposal, and recycling systems) <br />1 4( <br />4 <br />20. Designated Facility Owner or Operator Certification of receipt of hazardous materials covered by the marufest except as noted in Item 18a <br />Printed/Typed Name Signature ( Month Da Year <br />0� oT <br />v �-Z_ aV)-, le, <br />EPA form H7DU [[ (rcev, s uo) rrevaus saloons are Obsolete.0_0 9 _ 0 � f' 0 4 : 0 1 R C V DESIGNATED FAGLITY TO GENERATOR STATE (IF REQUIRED) <br />10171.2014 <br />