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- ������`� lilllfllllllllllllllllllllllll�llilll <br /> 0 0 6 7 7 6 4 0 2 S K S <br /> Please print or type. Form Approved.OMB No.2050-0039 <br /> UNIFORM HAZARDOUS 1.Generator ID Number 2 Page 1 of 3.Emergency Response Phone 4.Manifest TTrrac'kkiingg Numb e/r� (��[(� <br /> WASTE MANIFEST O O U ( f O `i�O 2 SKS <br /> 5.Gpgp Ilor's Name ar�_Mailing}Address __ Generator's Site Address(if different than mailing address) <br /> �E}Ci4-,J cYt;.ter ,.'•.;� f#:� ': <br /> p1pt Ii <br /> Generators Phone: <br /> _ U.S.EPA ID Number <br /> 6.Transsrter-��jo!nn}ttrytg <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 <br /> Facility's Phone: <br /> ga 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit <br /> 13.Waste Codes <br /> HM and Packing Group(if any)) No. Type Quantity Wt.Nol. <br /> 1 ( <br /> �h �qu <br /> Z 2. <br /> LU <br /> 3. i <br /> i <br /> 4. —_—�•—�j� <br /> J 9 I <br /> 14 Special Handling Instructions and Additional Information <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,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 the 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 quantity generator)is truQ. <br /> Generator'slOfferor's Printed/Typed Name _ Signature onth Day Year <br /> 16.International Soments <br /> i~ Import to U.S. ❑Export from U.S. krt of entrylexit: <br /> ? Transporter signature(for exports only): Date leaving U.S.: <br /> X 17.Transporter Acknowledgment of Receipt of Materials <br /> ILLJ <br /> Tr porter 1 P'nted(fyptp^ed N me S Month Day Year <br /> � e S r i i <br /> Z Transporter 2 Printed/Typed Name gnature Month Day Year <br /> H <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space ❑ Quantity ❑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 /> LL Facility's Phone: <br /> Hg Facility(or Generator) Month Day Year <br /> 18c.Signature of Alternate <br /> Q <br /> Z <br /> 0 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal.and recycling systems) <br /> LU 1. Z 3. 4. <br /> 20.Designated Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except as nded in Item 18a <br /> Printed Typed Name Signature Month Day Year <br /> EPAa �7�previouseditionsareobsolete. <br /> DESIGNATED FACILITY TO EPA's e-MANIFEST SYSTEM <br />