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Please print or type. ' Form Approved.OMB No.2050-0039 <br /> UNIFORM HA7Apj)iDUS 1.Generator IQ Number 2.Page 1 of 3.Emergency Response Phone 4.Martffest Trackin" '56 <br /> Number <br /> WASTE MANIFEST : '��'5 6 JJ�/ <br /> 5.Ganerato s Name and Mailing Address Generator's Site? dress(•f different than mailing address) n <br /> r <br /> Generator's Phone: <br /> 6.Transporter 1 Company Name <br /> U.S-EPA IQ Number <br /> 7,Tran*fter 2 Company Name U.S.EPA ID Number <br /> 9.Designated Faeikty Name and Site Address U.S.EPA 10 Number <br /> g r•s F.4 1 i <br /> Facility's Phone: <br /> ga• 9b.U.S"DOT Qescrtp#m(including Proper Shipping Name,Hazard Class,ID Number, <br /> fO.Containers 11"Total t2.Unit <br /> HM and Packing Group(ff any)) No. Type Quardity INt Not" 13.Waste Codes <br /> 1" <br /> I IN <br /> .� � <br /> 2 2. <br /> w <br /> C9 <br /> 3. <br /> 4, <br /> %4-Speclal Handling Instructions and Additional Information <br /> .- - - t�r E '•i' "i��{};`.f}`.,#!{- -y�%V1(�:fr m` <br /> 15, GENERATDR'SIOFFEROR'S Cr:WnRCATION: I hereby declare that the contents of this consignment are fully and accurately described above by M proper shipping name,and are etassi6ed,packaged, <br /> marked and labeledlplacarded,and are in ail respects in proper condition for transport according to applicable international and natiorral govemmental regulations,If export shipment and i am the Primary <br /> Exporter,I osrtify that the contents of this consignment conform to the terms of the attached EPA Acknowledgment of Consent" <br /> i certify that the waste minimization statement identified in 43 CFR 262-27(a)(if I am a Large quantity generator)or(b)(KI am a small quaffo generator)is hue. <br /> Generato;`VCtferor's NnteCyped Name Sig re fufortlh Day Year <br /> _j 16.international Shipments <br /> t— ❑k'portto U"S" ❑Export from U.S. Port of enhylexit <br /> Transporter signature(for exports only): Date leaving U.S.: <br /> LU 17.Transporter Admowledgment of Rem ipt�f Materials , <br /> Transporter 1 Pdntedlf)rped Name L F ! Signature Month Day Year <br /> A <br /> t i •i <br /> Transporter Priniedfiyped Name Signature +� Y Month Day Yearl <br /> 18"Discrepancy <br /> 18a.Discrepancy ladication Space <br /> Quantity ❑Type ❑Residue ❑PartiaE Reysction ❑Full Rejection <br /> Manifest Reference Number. <br /> 184.Alternate Facility(or Generator) U.S.EPA ID Number <br /> J <br /> c3 <br /> Fatuity's Phone: <br /> LOU IBe-Signature of Altemate Facility(or Generator) Month Day Year <br /> a <br /> x <br /> 9.Hazardous Waste Report Management Method Codes¢.e.,codes for hazardous waste treatment,d sposal,and recycling systems) <br /> 4, <br /> 20.Designated Facft Owner or Operator Carlificatlon of receipt of ha2ardous materials covered by the manifest except as noted In Item 10a <br /> Pdnte )ped Name S'Hato <br /> Month Day ear <br /> EPA Farm 8790-22(Rev-'12-1 7) Previous editions are obsolete. <br /> TRANSPORTER COPY <br />