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Please <br />print or type. (Form deslgnert for usenn elif� (12 pitch) typewriter:) Form Approved: OMS No. 2050-0039 <br />UNIFORM NAZARI5016S <br />WASTE' MANIFEST <br />1 erierato� IDtNujmbjerf <br />A/ g 490 <br />2. P3age 1 <br />3. Erne en Response P one <br />& j <br />4. Manifest {Tiraackin Number C t <br />:i C L <br />5. Generators Name and Mailfin Address Generator s Site Address (if d' ren Pan mailing rens) <br />7 t�IrvEa'h3Cp' �r �4i�1l{ /4�"f.' y r i' + .s <br />d f`iC .6/j( C. <br />ar <br />f j1zsJ <br />— s+s <br />r s <br />8 Li35t9na rsd F 3nll 39ame�and.Sdpe ss [) LI U.S. EPA ID Number <br />• <br />� � Yi r tom® <br />.�p <br />facility's hone: .� s' r&C,4l )101-141 <br />ga <br />9b. U.S. DOT Description (including Proper Shipping Name, Hazard Class, ID Number, <br />10. Containers <br />11. Total <br />12. Unit <br />13. Waste Codes <br />Type <br />HM <br />and Packing Group (if any))No. <br />Qua <br />ZIPWt:A%I: <br />ZI <br />d <br />r� - <br />., . <br />Lia <br />LJ A 1 <br />a2l <br />All <br />3. <br />4. <br />14. Special Handling Instructions and Additional Information <br />,F <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, and are classified, packaged, <br />marked and labeled/placarded, and are in all respects in proper condition for transport according to applicable intemationai and national governmental regulations. 9 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 alarge quantity generator). r (b) (it I am a small quantity generator) is true. <br />Generator'sl0fferoes Printed/Typed Name Signatur Month Day 7ear <br />06 <br />Z <br />16. International Shipme is J <br />❑ Import to U.S. ❑ Export from U S Port of entry/exit: <br />Transporter signature for exports only): Date leaving U.S.: <br />17. Transporter Acknowledgment of Receipt of Materials <br />ransrinted/Typed NWe Signa Month Day r. ear <br />IL.fes <br />N <br />I <br />Q <br />Tiansporfer 2 Printed/Typed Name I 51990ture r Month Day Year <br />18. Discrepancy <br />18a. Discrepancy Indication Space <br />❑ Quantity El Type ❑Residue ❑Partial Rejection. El Full Rejection <br />Manifest Reference Number: ` <br />18b. Alternate Facility (or Generator) U.S. EPA ID N=15er, <br />J <br />U <br />Q <br />Facility's Phone: <br />J <br />18c. Signature of Alternate Facility (or Generator) Month Day Year <br />Q <br />Z <br />19. Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste treatment, disposal, and recycling systems) <br />LLJ 0 <br />1. <br />2. <br />3. <br />4. <br />1 4,------� <br />1 <br />20. Designated Facility Owner orator: Certification of receipt of hazardous materials covered by the manifest except as n ed irdtem 18a,," <br />Pnnfed/T . Name �,r Signature f Month Day Year <br />— ( -1 P` <br />LVId. <br />r=rr1 rorrn o r uu-« trcev. 3-uol rrevrous eamons are oosolete. <br />DESIGNATED FACILITY TO GENERATOR <br />