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Pfease print dr type. (Form designod for use on elite (12 -pitch) typ
<br />UNIFORM HAZARDOUS i. Generator lD Number
<br />WASTE MANIFEST l•,Aj,(Iti��4
<br />5. Generators Nama and Mailing Address
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<br />Generator's Phone: �`1+a?'F;s !`�L�1G��R? Q
<br />8. Transporter 1 Company Name
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<br />iUlti Irwiuslfial CYr.
<br />'� � "'" `" ""1 ¢4"'-""' - �-U.S, EPA ID Number �-
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<br />9b.U.S.ODTDescdption(including Proper Shipping Name, Hazard Class,ID Number,
<br />10. Containers
<br />11. Total
<br />Hht
<br />and Pecking Group ('deny))
<br />12. Unit
<br />13 Waste Codes
<br />No.
<br />Type
<br />Quantity
<br />Wt.NoL
<br />1
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<br />14. Special Hemlling InsWctlons and Addlllonal Infonnalion
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<br />15. GENERATQR'9lOFFEROR'S CSRTIFICATION: Thereby declare that the conlems of this wnslgnmenl are fullyand accurately described above by the proper shipping name, and are classified, packaged,
<br />marked and labeled/placarded, and are in all respects in pmpar crondlllon tar transport accoNing to applicable Inlemalionaland nefwnal governmental agulaUons. Ifexport shipmenland I amthe Primary
<br />Exporter, I cerOty That the contents of this consignment conform to the terms of the attached EPAAcknowledgment o(Consenl.
<br />I cediry that the waste minimizaVon statement identlfied In 40 CFR 262.27(a)Ciflamelarge quanlilygenerator)or(b)(Alamasmall quantity generator)is true.
<br />GeneralorsfOBe��ro++r's Prinled/(yped Neme Signahtre Month 'Day Year
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<br />76. Iniernalional Shipments
<br />`� ❑Import to U.S. ❑Export
<br />from U.S. Port ofenlrylexil:
<br />Transporter siynalure (tor expods only): Date leaving U.S.:
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<br />iT.TanspoderAcknowledgmenl of Receipt of datedals -
<br />7 der 1 Pdnted/rypp,,d _ e � Signature 's..� __ - � Month Day Year
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<br />Tans r2P ted Nama Slgnalua ��o- Month Day ear
<br />18 Dmcrepancy
<br />t0a Di repax(A�Indicalion Space
<br />�ff,„, !.+ ❑Quantity Type ❑Ridue ❑Partial Rejedton ❑Full Rejection
<br />_. "__ _. _
<br />Manrtest Refeance Numhar:
<br />tOb. Aflemate Facility (or Generator)
<br />U.S. EPAID Number
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<br />u¢-
<br />Facility's Phone:
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<br />10c. Signature ofNlernale Fasillty(or Generator)
<br />F-
<br />B
<br />Month Day Year
<br />w19.
<br />Hazallous Wada Report Management Method Codes(i.e., codes for haurdeus waste lreatmm�l; disposes, and recycling systems)
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<br />t' 2. 3: 4.
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<br />20. Designs ed faculty Ovmer or Operaler. Certification o(recelplolhazardous malenals covered by the manifest except as nded in Item l0a
<br />PdnledlTyped Name r` Slgnalura Monts Day Year
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