|
I Pit
<br /> it Pit I ,11 a ; Qt
<br /> I
<br /> I9
<br /> ! tIV
<br /> PI n t erF ; rin desi red for+use oq ell4'i 12'-- Itch evrfiter. r� 4 i ) FormApple
<br /> wed OMB No. 2050.0038
<br /> YP ( 9 p ( P ) t ) 1 3 C.
<br /> 1 G Generator ID Number " 2 P gg 1 Af 3 Em [ enc Respo se Phoge 1: 4 Man f t Tracking Number
<br /> LFNI ORM HALARUOUS r = . . >a na » 3 , ,' " br°, Y F;9 ' uh.. b 'k 9` 4s, . T gv9j
<br /> ASTE MANIFEST - av K' = - s `' > n ...- 0 ".i rr e
<br /> „ F enerat i' N me and MailiI ones Generators Site Address ( f different than mailing address)
<br /> �- . 5' 1 - -
<br /> I it
<br /> Q I% - „ 4
<br /> Generator's Phone:
<br /> 6. Transpgrte� lC mpanyN e - U.S, EPA ID Number
<br /> ib cr - dIr f P. +. 1, sass , .P..'Al4 , :
<br /> 7. Transporter 2 Company Name - 4S, EPA ID Number
<br /> PIP, t
<br /> L.
<br /> 8. Designated Facility Name and Site Address rtr ^ 6K s n' = _ Y ;, g.,r „ d4 U.S. EPA ID Number -
<br /> 14
<br /> 8 PI
<br /> _, -
<br /> Qi
<br /> ttS, b , ,l ¢ .,3F if Y'-.. f. .
<br /> Pill
<br /> Fmcifidys Ph-one:
<br /> ga 9b. UPS. DOT Description (including Proper Shipping Name, Hazard Class, ID Number, 10. Containers 11 . Total 12. Unit 3, Waste Codes
<br /> HM and Packing Group (If any)) No. PPPPType Quantify WtIVOI.
<br /> 1taa9y s €
<br /> it rft ..� a4� na ? ,q
<br /> it
<br /> all 2 t i J z3 rt 9J tt nfAqP ' rlp-I ( € (` a'rM.,tjYe6°ya . P.
<br /> cn ttKii:! tII 1 rf - V- 21, s , . .� rd�Ce lit
<br /> 1 If
<br /> 3. - -� r y s i1 -
<br /> _ _..�.1......_.......�
<br /> 4 IQ
<br /> Special Handling Instructions and Additional Information } b.r z t } i ,: P PP. .it PI I �
<br /> d it,
<br /> � VIP
<br /> . . ry rt tgA { Ag
<br /> al _ }v. t t. 1 � , gnaj �.r�9
<br /> . i`, ' Uk r rf°.t= r F a . Y" 1. r ., sc r & , '�,. r , rtg SE7: .
<br /> 3 . . 1i: , a",v wIt .h .;+ A�E ;^ ..if, 'I .F ; �. ,,3ti2 v, _i _ ,Xti"s 7,..T3f ' 3 G' r w 's . .
<br /> 15.. -GENERATOR'SIOFFEROR'S CERTIFICATION: I hereby declare that the-contents of this consignment are fully and accurately described above by the proper dripping name, aM are classified; lockup ad
<br /> marked and Iabeledlplacarded, and are in all respects•in proper condition for transport according to applicable International and national governmental regulations. if expert sfi'ipment and 4am the Primary '
<br /> .'Exporter, Icertlfy that.the contents of the consignment conform to the terms of the attached EPAAcknowledgment of Correctly. '
<br /> :I certify that the waste minimization statement identified in 40 CFR 262.27(2) (if I am a large quantity generator) 'or.(b) (IfI am a small quantity generator) is true.
<br /> Generatorya)ffia is P t d/Typed Name - - Signature/ �' - L Month Day Year
<br /> It
<br /> 1.. �r.1 ., ,. L � , :�, ya v Y -rit .� _ �: p ' . . '
<br /> —r 16. International Shipments 4 - �, %"'
<br /> o-r ❑ Imp`ud�to U.S, - ❑ Exp rtiraIn U.S, Pon of entrylel L L
<br /> _
<br /> Transporter signature (for exports only): _ - Date leaving U.S.:
<br /> w ' 17, TransporterAcknowledgmelf of Receipt of Materials - - L - -
<br /> P Tr reporter 1 Prmtedryped Name Sign g[Euµ= Month Day- Year
<br /> gvj sit
<br /> z Transporter 2 Printed/TypPed•Nahie Signature "'v' - Mo th Day Year _
<br /> Q ,s �'� _ f �' 'w . . rD
<br /> l e-lin-, I � �
<br /> 18. Discrepancy �� - - -
<br /> Vie. Disr gancy Indication Space ❑ Quantity . ❑ Type L ❑ Residue '❑ Partial. Rejection - ❑ Full Rejection
<br /> Manifest Reference Number:
<br /> h-. l8b. Alternate Fal (or Generator) . - - U.S. EPA ID Number
<br /> Faciltys Phone: - - - -
<br /> w :18c.Signature of Alternate Facility (or Generator) - - " Month - Day Year
<br /> Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste treatment disposal, and recycling systems)
<br /> 2.
<br /> CHHVP # c 'PI
<br /> P,
<br /> 20. Designated'.Fzcility Owner or Operator. Cc fication of rel of hazardous materials covered by the manifest except as nofedin Item 188 1 1 -
<br /> PrintedlTyp dlpani �.,— ]1 Sig_natur h r _ - _ - Month Day Ye2h
<br /> EPA Fq[in 9 'Lt7p02 (�. qv 305) / Previous,edii,s are obsolete _ ,w ptq ( Pdip�'Q' 0p A6CE9,'g'Fi--1('-1TQ3 .S'a E�ERd1TCBB%
<br /> rr) ..i`a r.. , a , -r Tt ! x`. z ,I V1. . tr.( t 1a3 ., .ii ,i. ,
<br />
|