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rti r :�x t s. A°::1_'1.;` ":a Approved, Fleas int or type, (Form designed for use on elite (12-pitch) typewriter.)V.rJ a, Form A pp ed. OM8 Na. 2050.0039 <br />1, Generator ID Number 2. page t of 3. Emergency Response Phone 4, Manifest Tracking Number <br />UNIFORM HAZARDOUS } �'' ` ` '"^ [^ c <br />� � a� LC <br />WASTE MANIFEST ). r.., 0 fD 4 � :} "k} � i_ tr�itjill :1?? �-'�f3 `�� �J J r...r' 1— <br />5 Generator's Name and Mailing Address Generators Site Address (if different than mailing address) <br />f of o r'.Ye`13.ri ii <br />M1M1L//kl(�u <br />rrV5� <br />AJ."'f S`I uC7•[bii' c. Rj JfA'{��k`r� P� f�r'l4_ <br />Generator's Phona: 1`2091 r i f3 4F`a d'Ci <br />6.Transporter 1 Company Name U.S. EPA ID Number <br />aloviit(?cif Fs ?',Iii 33Yif3fS3 SSC ti 8tivirx '110 W, P, 1Y.) 0 -a 9 3 2 2 !C' 5 0 <br />7. Transporter 2 Company Name U.S. EPA Ip Numher <br />two <br />8. Designated Facility Name and Site Address U.S. EPA ID Number <br />C_-eafl51p,'bQrs-Sail };-!;Ilk GAG(t.. 94 c10 3i. is <br />1.x+21 Bereves5 , t�fa�l <br />Facility's Phone: f4i) ffi 44 J, -0 9 'R? <br />9a. 9b, U.S. DOT Description (including Proper Shipping Name, Hazard Class, ID Number. too Containers 11. Total 12. Unit 13. Waste Codes <br />Hfi and Packing Group (if any)) No. Typo Quantity WI.NoI4 <br />i. <br />4 42077.1.1A01A; OO1)-S VNA91E� , GOL!F}, 14. wS,. (L?1::VRISq iff3.� -A <br />t:: N, tP; ttfif t� WITH rll fvl.1 U 9,i' a 9t U _ 6 0 <br />, <br />w <br />2. <br />4, <br />I <br />14. Special Handling Instructions and Additional Information <br />el J <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 cdnsi irmenl conform to the terms of the attached EPAAcknwvledgment of Consent, <br />I comfy that the waste minimization statement identified in 40 CFR 262.27(a) (if I am a large quantity generv,lor)or (b) (if I am a small quantity generator) is true. <br />GeneratotstOBeror's Printedrfyped Name gnature ; _ x gni ay Year <br />16. International Shipments <br />❑ Import to U.S. ❑ Export from U S. Pbd of entry/exit: ____,_ _,_...._-..._...__.............�_ _._. ____. _ <br />.J <br />PM <br />Z <br />Transporter signature far exports onl p. Data leaving U S <br />17. Transporter Acknovviedgment of Receipt of Materials <br />UJ <br />1 <br />Transpo(rter1I Piin%tedflyped Name Signature Monthay Year <br />CL <br />/ 1 <br />Al 41-f <br />QTransporter <br />2 PdnledlTyped Name _ _ Signature A oh ay ear <br />8. Discrepancy <br />1r f <br />18a. Discrepancy indication Space C_7 Quantity ❑Type Ld Residue LJ Partial Rejection El Full Rejection <br />Manifest Reference Number: <br />16b Afternate Facility (or Generator) U.S. EPA 10 Number <br />J_ <br />V <br />Q <br />rr- <br />Facility's Phone: <br />18c. Signature of Aflemate Facil'ey (or Generator) Month Day Year <br />4 <br />Z <br />y19. <br />Hazardous Waste Report Management Method Codes (Le, codes for hazardous waste treatment, disposal, and recycling systems) <br />LU <br />z. <br />�. <br />4 <br />t.N J-4 :1 <br />20. Designated Facility Owner of,Operator: Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a <br />�jdnledlTyped NamerQ�nblure j f,j } Month Des lYar <br />ISM 10i Aul I t <br />EPA <br />Form 8700. 2 (Rev. 3&05) Previous editici0are obsolete,1 w� DESIGNATED FACILITY TO GENERATOF <br />f <br />