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Pi9a5e print or type. Form Approved.OMB No.2[)50-0039 <br /> fN'F6RMrllAZ' <br /> . IiDiJUS 1 Generator ID Number 2.Rage.1 of 3.Emergency Response Phone k Nfanifest Tracking Number <br /> WASTE MANIFEST f U. 9.01-4) i 6t�42a J 020.'.�688 JJK <br /> Generaa Name and Mailing � GerleraWs SbAddress I6 di ferentthan mailing address) <br /> ylln' crawl PIArn t W'bUYivl[t'i`13Pet <br /> nerator's.Phone: `AiJ 4 2-iZlTransporter 1 Company Name U.S.EPA ID Number <br /> •'-n!�+..y.y;c.:: f3 .y..,�.}. r;�• css-t��e:�r Iris• - t�f-Ei:l?iF'.:41.S i�-!3 <br /> 7.Transporler2 Company Name U.S.EPA ID Number <br /> 8,Designated Faclky Name and Site Address US.EPA ID Number <br /> ;=<-:,,-;IR�ir:gin•,es <br /> 7aa1 W_iith1 A <br /> Ltxig Oeat;1.L:A WM13 Reit <br /> Facility's Phone: <br /> 9,. 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10,Coniakii(s' 11.Tgtal 12.Unit 1S.Waste CodesNM and Packing Group Jif any)} Type Quantity Wt.Nnl. <br /> ce <br /> 1.Fir_•:;,r G�f'i�:Ay fS L. � ��.i'� ' t 1 LAO <br /> 7 <br /> u., <br /> 3. <br /> 4. <br /> K4 Speclal•f andii Instuctions and 4ddliEottal Irdormatton <br /> . .:'V ter frfi'.AVIS, Rags, Uebns a"VIR 1,(14 Weir?Wopn►xte Oxfvr�qr qogilraw <br /> 15. GENERATOR'SfOFFEROR'S.CERYkt:tCATION: I hereby dedare.fhat the oontents of this consignment are fully and accurately described above by the proper sh Wing name,and are classified,packaged, <br /> marked and labeledlplacarded,and are in allsespects in proper condition.for transport.according to applicable intematfanaland natlonal govemmental regulations.ff expart shipment and I am the Prtmary <br /> Exporter,I certify that the contents of tills mrrsignment=form to the terms of the attached EPAAdmwtedgmentof ConserrL <br /> I certify that the waste minimization statement identified in 40 CFR 262.27(a)(If i am a large quanffty generator)or(b)(ifI am a small quantity generator)is true.— <br /> Generator'slOfferor's PrhtedrTyped Name Signature r Month Day Year <br /> ke <br /> 16.International Shipments <br /> i— ❑Importia U.S. ❑e=xport herr,US. �}} Port of entrylexh: .t <br /> ? Transporter signature(for exports only): Data leaving U,L. <br /> LU <br /> 17.TransporterAcknovdedgment of Receipt of MaWals <br /> Transporter 1 PdntedlTyped Name Signature. ? r Month Day Year <br /> Transporter 2 Printedrryped Name Sfgnahrre 9 mom Day Year <br /> 18.Discrepancy <br /> 184.Discrepancy Indication Space. ❑ nuantity LiTYP ❑Residue 0 Partial Rejection:... ❑Full Rejection <br /> Manifest Reference Number. <br /> 1 Rb-Alternate Facllity(or Generator) U S;EPA ID Number <br /> U <br /> u Facility's phone: <br /> LU 1&.Signature of Alternate Faculty(or Generator) th Day Year <br /> fulon <br /> 9.Hazardous Waste Report Management Method Codes(€.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> 2. 3. fi.'x1/// I . . 1 <br /> 20.Designated`Facility Owner or Operator:Certification of receipt of hazardous materials covered by the mandest except as nded in Item 1Be <br /> Name SignMonth Day Year <br /> EPA Farm 57D0i?'( av,12i J Previous a loans ar obsolete. TRAN5PQRTER COPY <br />