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SSL Sh 6H!P# lie�:--=-b111111111111111111111111111111111111 7- 3'730ga 9 0 0 5 3 0 5 5 3 2 S K S Please print or type. Form Approved,OMB No,2050-0039 UNIFORM HAZARD 1 Generator Ill Number LHL@00f 694taib6 2.Pae 1 of IL I.Ern � ��n�R6p 1g 4Oanifest Tr�cki� k►er3 KS WASTE MANIFEST !!C}YJ CO vg 3 t[J� 8 S.Generator's Name and Mailing Address Generators Site Address(it different than mailing address) f1' 14l' Ily # 4 1 1 ab 113 S Harlan Rd GeneratorsPhone- 134-189b 5.�W"!��k7Y e Y`Y f frF I NL. U.S-EPA 10 Number (k-1 1616081 H T.Transporter 2 CommName U-S.EPA ID Number ILL VON' FiFit�rit3HS ENV SVL lNL. r4HU0 y112L-. w 8-Designated Facilhty Name and Sim Address CLEHN hAH BURS bRHSb'r MOUNTAl N U-S-EPA 30 Number 3 MiLES EilSl, ! MILES NL' K)H }[NULLS I«X1'! 41, UFS i—BW KNOLLS , Ulf 640 83 ��:.-•tlSjF—$`J 1� U 1 V!':7 1-�t!I 1 148 Facility's Phone: 98. gb.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit 13.Waste Codes HM and= g Group(H any)} No. Type Quantity WtNd- 1 • NON--RCRH HAZARDOUS WASTE, SULIU, I bm f� N 181 [NfiSbRbENl i-iWD Li1L ), -O"C W C7 3. 4. 14.special Handling Instructions and Additional lnlnm,atbn 3 Sl)::bm 1]I{ 51 ib L„SG d4H retained by generator conteru agency autharxt an initial transporter to ace at, substitute addxtxonai transporters an ener',atvr•' S behait. 15. GENERATOR'SIOFFEROWS CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by the proper shipping name,and are classifted.packaged, marked and labefeWpfaGarded,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)fif IpT a small quanttty ganerator)is true- Gener is ' led Name Signature Month Day Year Com- 10 z� ematlonal Shipmen s F ❑Import to U.S. ❑Export from U.S. Port of entrylexit: Transporter signature(for exports only): Date leaving U.S.: X 17.Transporter Acknowledgment of Receipt of Materials T iter 1 PrintedrTyped Name �p Signature Month Day Year ZTjnsport er 2 PrinledlTyped Name Signature Month Day Year 18.Discrepancy 18a-Dlsempancy Indication Space ❑ Quantity ❑Type ❑Residue ❑Partial Rejection ❑Full Rejection Manifest Reference Number- 18b.Alternate Facility(or Generator) U.S.EPA ID Number J_ LL Facility s Phone: w 18c.Signature of Alternate Facility(or Generator) Day Year d x n19.Hazardous Waste Repan Management Method Codes(i-e-,codes for hazardous waste treatment,disposal,and recycling systems) � 1. L 2. 3. 4. I20-Designated Faces' er or Opti r.Cermcsfiq< ipt of hazardous materials covered by the manifest except as noted Item 18a 7L-75 Mgt) PrintedFFyiped Name gnatureMonth Day Year I "I � 1-M - I --hhak-1, 1 ,G N L E1pA F I1100.-22{R9v.1 121 Pr�vbus edition are obsolete- DESI ATEC FACILITY TO EPA's e-MANIFEST SYSTEM