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65L bK bH1P# -L3 �Vis, Illllll�llllilllllllllliflllllllllll Please print or type. O O 5 4 0 a 5 0 K arm Approved.OMB No.2050-0039 UNIFORMLMANIF:EST AUS�Generatorr 2.Pagge 1 of 3.Eme�rg e�ncy Respponse Phone 4.Manifest Trackin Number L:HLk�Y!ld.;ySC4� t 1-ti%jL4btf-I lbid g WASTE 008539035 S K S 5.Generator's Name and Mailing Address Generator's Site Address(if different than mailing address) U' Kexlly # 54/1 4dW W Lady Hve LUlll LH 3�rt4Y1 J46.5 bene ator's Phone: `V!`3-,Sb1-1 dd Transporter 1 Company Name w U.S.EPA ID Number Ft!Y-KLtEN 5Yb 1 EP1b 1NL !X.X►d0r[?tdttictdn 7.Transporter 2 Company Name U.S.EPA ID Number L<LEHN HHKBUKb ENV bVL: 1NL;. �+tHt�FdS`��cc:c�rtd 8.Designated Facility Name and Site Address L:LEHN HHKBUKS 5HN J UbE U.S.EPA ID Number ItdEl MEXKYEbbH KUHV aHlV J USE } LH `1:►1 du 406-441-ir?jbc 1:f llt11)'j4"3451�d Facility's Phone: ga, 9b:U:S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit HM and Packing Group(if any)) No. Type Quantity Wt.Aol. 13.Waste Codes 1� � NUN-XL;XH HHLHKiIUUS WHbtE, bULiV, Dm 0 IliItil j i 0 bi UXL�ENf HNU U1L), .G_ 3 Z 2. w CD 3. 4. 14.Special Handling Instructions and Additional Information !6L) SJ 81J tali d C� LCX 144 r L bU: E4H Ei'gtHbLi'4L,Y4600-466-1lbW-LH/bK lFi-L:ontract retained by generator canters agency authorat on i ir r s ,Y 15. GENERATOR'SIOFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by the proper shipping name,and are classified,packaged, 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 am the Primary Exporter,I certify that the contents of this consignment conform to the terms of the attached EPA Acknowledgment of Consent. I certify that the waste minimization statement identified in 40 CFR 262.27(a)(if I am a large quantity generator)or(b)(if I am a small quantity generator)is true. Generator's/Offeror's Printed/Typed Name Signature Mo th Day Year -5 �1�� .Z J 16.Interna' Shipments z ❑Import to U.S. ❑Export from U.S. Port of entry/exit: Transporter signature(for exports only): Date leaving U.S. W 17.Transporter Acknowledgment of Receipt of Materials w F- Tran o r 1 PrintediTyped Na Signature O M Day Year a z Transporter 2 Pri ecr yped Name Signature Month Day Year 18.Discrepancy 18a.Discrepancy Indication Space El ❑ Quantity Type ❑Residue ❑Partial Rejection 1 ❑Full Rejection } Manifest Reference Number: 18b.Alternate Facility(or Generator) U.S.EPA ID Number J U LL Facility's Phone: UO 18c.Signature of Alternate Facility(or Generator) Q~ Month Day Year z 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) LLJ 1. 2 3 4. 20.Designated Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except as noted in Item 88a Printed Typed Name Signature Month Day Year EPA Form I dtj/,f 4i0JJ�b�,i:7 2(Rev.12-17) Previous editions are obsolete. 1.) ;f,3b1LJ`. DESIGNATED FACILITY TO EPA's e-MANIFEST SYSTEM