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•"` 69L ; I 5K it . <br /> PI eF`ti5��feslcjhed fo" (Isa� li '1 -pitch)yypevpiter.} •'�° f j tk ' Form Approved.OMB No.2050-0039 ' <br /> 1.Generator ID Number 2,Pa e 1 f 3. R spo se pgI�e 14.Manifest Ira Kin Number j <br /> UNIFbRM.tiAZAl3 OUS CARI�00A3970_ r•`�'d <br /> WASTE MANIFEST t 0 0 6.3 16 4 9 SKS <br /> Generators Name and Mailing Address Generator's Site Address('d different than mailing address) <br /> Escalon Premien Bra1,dS`Inc -` <br /> I5 Mchenr�y .Au,.e <br /> ESCALON :. �- GA 953ali-9601 <br /> Generators Phone: `� * �' � <br /> 6.TpsAoc11aLn �t SYSTEMS INC U.S.EPA ID Number TKR000081205 <br /> T.Transporter 2 Company Name U.S,EPA ID Number <br /> CLEAN HARBORS ENVIRON ENTAL SVG INC. MAD039322250 <br /> 6..Designated Facility Name and Site Address .C�.EAN R C--' ENVIRONMENTAL SERV I CES, ]N U.S.EPA ID Number <br /> 2247 S HI WAY 71 <br /> KIMBALL , .NF 6J145 <br /> 346-2w5- 812 <br /> 'Fpcility's Phone: <br /> 9a. 9b.U.S.DOT pescdp8on(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11,Total 12.Unit 13.Waste Codes <br /> HM and Packing droup('d any)) No. Type Quantity WWol. <br /> X '1 UIV3082 I WASTE, <br /> ENV I P,0XV11F.NTALLY HAIARDOU / DM IAO() P D008 D6181223 <br /> o S ,SUBMNCE6, LIQUID, N.0.5,+, (LEAD, <br /> FS �A <br /> RtENE), 9, RG In <br /> uWz,' 14 2. UN190wi1 DISINFF-CTANTS LIQUID Q P 14-I <br /> CORROSIVE Ni.0,S. (OU✓�TENARY �WONTLIM <br /> COMPOUNDS),, B, [ & ,I i I <br /> 3. — - <br /> Uri <br /> 4.AM1 NO <br /> Special Handiipg'InstructlonsandAdditionallnformation TS.KR i �Qy� 6C� E°ti7�I 15 E3y <br /> i)�ERGt�171••2?l�.Rl311ri�.t3• <br /> �e H E,�1ERG�NbY#800-4AS-1760-CH/S`i{ITFI-Contract retakned by �erieratl;or Confers agency a utrh 0 In ii v '. <br /> on initial transporter to add or 'substitute additional transoorte_rs on- taenfliratort s behalf. ' <br /> 15.. GENERATOWSIOFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and'accuratety described above by the proper shipping name,and are classified,packaged, <br /> marked and labgledlplacarded,and are in all respects in proper condition for transportaocording to applicable international and national govemmental 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 EPAAcknowledgment of Consent <br /> l certify that the waste minimization statgrgent identified i O CFR 262.27(a)('d I am a large quantity gen.erat4)'or b)(if I am asmall quanfity generator)is he. <br /> Generadoe ®ff roes Prin*jyped Name Signature r Month' :Day ' Year <br /> 11 17A <br /> 6.International Shipments e + <br /> 4; :. ❑ImporLfO U.S. ❑6 pari from U.S. Pgrt of entrylexik <br /> z Transporter signature(for exports only): Date leaving U.S.: <br /> W 17.Transporter AclmoWbdgment of Receipt of Materials <br /> O T s ' <br /> port *erIPdntedlldSign " Month, Day.Name Year <br /> a t m it 0 it D . <br /> M Transporter 2 Pfinted/T N e Signature '��� Mo Day. Year. <br /> 18.Discrepancy <br /> Disfi4pancy indication Spars ❑ Quantity ❑.Type ❑Residue Partial.Re ection <br /> ❑ J ❑Fult Rejection <br /> • t <br /> ( Manifest Reference Nun>ber. <br /> •.18b.A)lemate Facility(or Generator) i t ' U.S.EPA ID Number i +` <br /> I Facilityrs Phone: <br /> La J8c.5i!n tura of Alternate Facility(or Generator) Month Day = Year <br /> Q <br /> J Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous Waste treatment,disposal,and recycling systems) <br /> 20.Designated.Facility Owner qrOperatoC Certification of receipt of hazardous materials covered by the manifest except as n*d'lh 1161 Be <br /> Pdntedfiypedme Signature. Month Day Jr- <br /> EPqq'Fo' 8 5} Pr ou e i e o I t . ` <br /> ESIGNATtO.FACILITY TO GENERATOR <br />