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Please Drint or tvDa. (form desioned for use on alga t12-nitchl tuoawriter I <br />Form Anomved. OMB No- 2050-0039 <br />kh'A Form eruu-12 (Kev. s-ub) rrevious earaons are aosoew. utWUNA I tv I-At,111-1 I r 1 V Or-11CR14 1 Mn <br />UNIFORM HAZARDOUS <br />I'-G—'or'DNumb0r <br />2. Paget of <br />3+F ��Re ,sparse ��ildumber <br />ll <br />� O O � � � /�4G ry JJ K <br />WASTE MANIFEST <br />"-'' 1� <br />5. Generators Name and Malin] Address J yy� Generators Sita Address (If r50ererd Oran rnaYing address) <br />G. Transporter 1 Company Name U.S. EPA ID Number <br />7. Transporter 2 Company Name U.S. EPA tD Number <br />8. noted Pacdhy NUS- EPA ID Number <br />��i1'r^`d- 1r' 1�. v �E tY c: t.t•.,. 'j"'�E:.l-:�i U'.^•c f-�'i" <br />Fs Phone: <br />ga. <br />9b. U.S. DOT Description (indu(fing Proper Shophg Name, Hazard Class, ID Number, <br />10, con elne s <br />11. Total <br />12. Ung <br />13. ynb Dada <br />No. <br />Type <br />HM <br />end Packing Group (K any)) <br />Owntity <br />WAIW <br />� <br />t r. / ..A ...�,lG- TS f E'��1�.'.y.5 ] ��i"�'G�..'��"�rJ S �l <br />jr�'!T•�� <br />LU <br />lS <br />3. <br />4. <br />14. Special Handling Instructions and Additiowl Information <br />15. GENERATOR'SIOFFEROWS CERTIFICATION: I hereby declare that the contents of tltis consignment are ftlty and aocurv* dwarbed above by the proper s *"V name. and are classified, packaged, <br />marked and labeiedlplararded, and are in all respects In proper Wnfton for a'anepat aMWft to aMcable imema Wand na6aral govanrnerdat nigulabom g export shipment and I am the Primary <br />Exporter, I catty that the contents of this consignment conform to the terns of the edached EPAAcknotMedgment of ConsenL <br />I certify that the waste minimization statement identifieed in 40 CFR 26227(a) (if I am a large quantity generaw) or (b) (d I am a amali quantrly generator) a mw <br />GeneratV&0 Prfrrtedlfyped NeapSignature �i Month Day Year <br />J <br />16. International Shipments Import toU.S. El wort tram U.S. Podoleri"fot <br />- — <br />Transporter signature (for exports wty): Dae leaving U.S.: <br />ce <br />17. TransporterAdmvrAedgment of Rawiptof Materials <br />Signahue Monts Year <br />Transporter 1 Printedlfyped Name _ <br />Transporter 2 PrintedfTyped NameiSignature Month Day Year <br />t- <br />18. Discrepancy <br />18a. Discrepancy India� <br />bon Space Outity 0 Type D Residue Partial R*don Full Rejectim - <br />Atxrifast Reference Number <br />18b. Alternate Facility (or Generator) U.S. EPA ID Number <br />v <br />SEP <br />LL <br />Facility's Phone: <br />18c. Signature of Alternate Facility (or Generator) M" <br />Z <br />S2 <br />disposal. systems) ' n <br />19. Hazardous Waste Report Management Method Codes (La., codes for hazardous waste treatment, and recycling <br />G <br />1. <br />2. j <br />3. 4• <br />20. Designated Facility Owner or Operator CediAation of reoeipt of hazard rts�r ler als covered by the mamfast except as noted in Item 18a <br />PdntedlTyped Name ' S'prrebrte Month Day Year <br />"- - �` — <br />kh'A Form eruu-12 (Kev. s-ub) rrevious earaons are aosoew. utWUNA I tv I-At,111-1 I r 1 V Or-11CR14 1 Mn <br />