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f.. <br /> Form Approved.OMB No.2050-0039 <br /> -4RM HAZARDOUS 1.Generator ID Number 2.Pae 1 of 3.Emergency R g <br /> «L tiw i i w Ai 9 9 ncy espouse Plane 1. Tracking Number1")3581007 <br /> O 7 JJ K <br /> WASTE MANIFEST tfUt_,-'�1t5-1..1�i: <br /> I r 5.Generators Name and Mailing Address Generators Site Address H different than mailingaddress <br /> t w't-W E MAJ141�f <br /> Generators Phone <br /> 6.Transporter 1 Company Name U.S EPA ID Number <br /> AIYIi_S?7 ?�l5/AOLf_L ti / 7 ff:i.q! .I!') �RM�0177-W <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> u6rt�i�+_U+V1l.J!_kL+„i.�sll�k Y 5 t S i thAS Iht(; „A}ill(}p 1'I64T1 <br /> 8.Designated Facility Name and Site Address Y LIMA Y Ez�2 wxA,i L: (HAW L N fAULIII Y U.S.EPA to Number <br /> 43.00 JJG HC#WAY 96 r"ziFZI 152114 <br /> AWA,A? 65385 <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 13 Waste Codes <br /> HM and Packing Group(if any)) No. Type Quantity WtNol. <br /> rY 1. I I0IxI-&r<_`-Fta�#-tA7-AK1D0LJS WADI; = <br /> 1 <br /> z 2. <br /> UJ <br /> C7 <br /> 3. <br /> 4. <br /> 14.Special Handling Instructions and Additional Information <br /> W(4-1[-&#200125/WS 7tF3SOR&EN i ENG 171 <br /> 15. GENERATOR'S/OFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by the proper shipping name,anti 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 l am a small quantity generator)is true. <br /> Generatoes/Offeroes Printed/Typed Name Signature Month Tay Year <br /> 16.International Shipments <br /> ❑import to U.S. L1 Export from U.S. Port ofentry/exit: <br /> rransporter signature(for exports only): Date leaving U.S.: <br /> 7.Transporter Acknowledgment of Receipt of Materials <br /> ansporter 1 Phnted/Typed Name Signature Month Darr Year <br /> VA <br /> 3nsporter2 Printed7Typed Name Signature Month Day Year <br /> Discrepancy <br /> Discrepancy Indication Space ❑ ❑Partial Re ❑ i <br /> L1 Quantity ❑Type Residue Rejection Full <br /> Manifest Reference Number: <br /> Alternate Facility(or Generator) U.S.EPA ID Number <br /> Y's Phone: <br /> gnature of Altemate Facility(or Generator) Month Day Year <br /> _ardcus Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) Notice: State of California requires <br /> 2. 3. generator to photocopy and mail to <br /> DTSC with 30 days: <br /> ana;ed Facility Amer or Operator.Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a P.0 BOX 400 <br /> �red Name <br /> I Signature Sacramento, CA 95812-0400 <br /> 22(Rev. 12-17) Previous editions are obsolete. GENERATOR'S INITIAL COPY <br />