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Please orint or t <br /> Form Approved. OMB No. 2050-0039 -- GENERATOR .. <br />UNIFORM HAZARDOUS <br />WASTE MANIFEST <br />1. Generator ID Number <br />C.pc-c_ ic-tc.'" \ 1-1-1 '1 Li <br />2. Page 1 of <br />I <br />3. Emergency Response Phone <br />A•oo 1,;2.-1-1 i I -.I., <br />4. Manifest Tracking Number _ <br />0197039 /0 JJK <br />Generators Name and Mailing Address Generator's Site Address (if different than mailing address) <br />Ars t=17-tribm'A--- ti--es rtteveirk-c- <br />1 o op 1.151-4440' 5 reafiE tc.4). --tz-A-14 -t-r_v <br />iztzAkr-tmt.)v, 1 v A- 1---S1—% St <br />Generator's Phone: ( ceo y ) 7.--51- 15 erc,c, I 11-43,--x.A1 0,-.Nrx y , <br />Transporter 1 Company A a m e I U.S. EPA ID Number <br />'Illoket-ta-kr- t--'vkt2-7.-1 -1.)-t-ott- 4,atz-vi_,----- I <br />-Fran der 2 C mpany Name( U S. EPA ID Number <br /> <br />-. ()V411DrA, Lific 1 CI409A‘c/0 4.-zoi t, <br />Designated Facility ternire and Site Address <br />CIF--•` SA'S •1 *, <br />1 (c3' '-s. 1 VII Sl- • <br />k_47*4 L. nosercirt I .=-1A— ''I=.46 t--3 <br />Facility's Phone: <br />U S. EPA ID Number <br />4_.Ac17)•-0-2_ tk oct 0 vzi <br />ga. 9b. U.S. DOT Description (including Proper Shipping Name, Hazard Class, ID Number, 10 Containers it Total 12. Unit 13 Waste Codes . <br />KM and Packing Group (if any)) No Type Quantity WI [Vol <br />1. V.) . as - r.4.1I-A, jAI2Vt.,4-1L-P14"1. LA ift-...etigr 1 sozt j <br />(ist49tfic•c5 .--/ coPeksw.ar 0 ( b1,4 Us- r <br />2. <br />14 Special Handling Instructions and Additional Information <br />J1*- 11----r__./5-9, <br />GENERATOR'S/OFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by the proper shipping name, ard 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 are the Primary <br />Exporter, I certify 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 40 CFR 262,27(a) (if I am a large quantity generator) or (b) (III am a small quantity generator) is true. <br />Generator's/Offeroes Printed/Typed Name Signature <br /> °1$C)%."-TS 'F'ir---1‘.r qt— -It-s-1,- S—Lervt I 11 <br />Month Day Year <br /> <br />I I‘o I Z-1 <br />....., <br />.... <br />International Shipments Export from U.S. t f entrlik <br /> Transporter signature (for exports only): <br />Import to U.S. <br />ate leaving U.S <br />re <br />ceW <br />0 0- <br />CO 5. <br />Transporter Acimowledgrnent of Receipt of Materials <br />Transporter 1 rintedfTyped Name Signature Month Day Year <br />— 14,‘ Ii-1•1 I I 6 Ilko 1-2-1 <br />Transporter rintedITyped Name Signature Month Day Year <br />loteli_119-1 I DESIGNATED FACILITY Discrepancy <br />18a. Discrepancy Indication Space III Quantity liii Type liii Residue 11111 Partial Rejection ril Full Rejection <br />Manifest Reference Number: <br />188 Alternate Facility (or Generator) U.S EPA ID Number <br />Facility's Phone: 1 <br />18c. Signature of Alternate Facility (or Generator) Month D,iy Year <br />Hazardous Waste Report Management Method Codes (I.e., codes for hazardous waste treatment, disposal, and recycling systems <br />1 <br />/4 I W 1 <br />2. 3 4. <br />Designated Facility Owner or Operator: Certification of receipt of hazardous materials covered by the manifest except as nded in Item 18a <br />Printeame Signature Month Day Year i <br />EPA Form 870042 (Rev. 12-17) Previous editions are obsolete. S e.