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Please print or type. Form Approved. OMB No. 2050-0039 GENERATOR *UNIFORM HAZARDOUS <br />.r. INASTE MANIFEST <br />1. Generator ID Number <br />AC--ide,-3 1 12-; <br />2. Page 1 of <br />AV I <br />Generators Site <br />3. Emergency Response Phone <br />9/6 - 5-63- 7110 <br />4. Manifest Tracking Number <br />0 1 9 3 2 8 8 3 2 JJK <br />Generators Name and Mailing Address 0 ba.), pt.:km(4;1%6o <br />1651 covoyta, 'We <br />, ScuA life. cfStg, <br />Generators Phone:I/6?-252- asigs Ilh: .).CArtrGI <br />, Ault>, . <br />I MA I • <br />Address ( <br />1 <br />it differentlhanling addressW <br />2/. <br />eli ?52.4) <br />Transporter <br />Psi\ <br />1 Company Name U.S. EPA I Number.. • . .. <br />Ell tif rOkliMehtaii I AC f [ CA- 000(73 64. 1 . <br />Transporter 2 Company Name <br /> <br /> U.S. EPA I Number • - . r <br />Z4I r 413/ x:eg,/44,11-. Vir.65-97 7 2/T -62.8 <br />Designated Facility Name anrSife Address ...> i_e_..4 iocri tskievacict, 1 ciz ,, - , - - U.S. EPA ID Number <br />• . . Wet/ 95. It I HOU 5'0 t,ct4 or BeAtif ' <br />• <br />AiV g if 03 ' <br />Facility's Phone Cl- 239.3,45 lav-F33090000 - - <br />ga. 9b. U.S. DOT Description.(iecluding Proper Shipping Name; Hazard Class, ID Number,. • 10. Containers - - "1-1. Total 12. Unit Waste Codes HM. , and Packing Group (if any)) No. :Type Quantity <br />- <br />Wt.Nol. 7 13. <br />1 44 rkC' 1 ifecza S-. Wok* ,s01; , •A OD a • CV DO ( howl, elk itseii -Pt Or oil, 4- igcle . . , . initrete4 'so, <br /> <br /> <br /> <br />14. Special Handling Instructions and Additional Information (ILI , t tics Fc.010,5 1 kil.c,:ti: 070.1 .2.s 306- 17/57 <br />(-4-/ 57_17 a 860 <br />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, 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 am 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) VI am a large quantity generator) or (b) (if) am a small quantity generator) is true. . . <br />Generator's/Offerors Printed/Typed Name. - ' Signature -- - - Month Day. Year <br />,, <br />A ulAorird ,4#r. LU :ler/Apt:1d lleivia7 -47Z 10 3PEI9`9 <br />_1 r- <br />M <br />16. International Shipments . • Import to U.S. Export from U.S. Port of entry/exit: <br />Transporter signature (for exports only): Date leaving U.S.: TRANSPORTER I 17. Transporter Acknowledgment of Receipt of Materials <br />Transporter 1 Printed/Typed Name S.gnature ' - „., Month Day Year <br />11 i%R- Mil ni4771/:h4S 1 10.3 lo 612 2. <br />Transporter 2 Pnnted/Typed Name Signature Month Day_; Year <br />-rhiAld-- Z3at/Vedeeel I -4,-/,--_ 1 7 1/-75- lgot DESIGNATED FACILITY --o• 18. Discrepancy <br />Discrepancy Indication Space Quantity , LII Type Residue Partial Rejection Full Rejection <br />Manifest Reference Number: <br />Alternate Facility (or Generator) U.S. EPA ID Number <br />Fadlity's Phone: 1 <br />Signature of Alternate Facility or Generator) Month Day Year <br />I I <br />19. Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste treatment, disposal, and recycling systems) <br />2. 3. 4. <br />20. Designated Facility Owner or Operator: Certification of receipt of hazardous materials covered by the manifesto <cept as nded in Item 18a <br />P d/Typed Narn62a._ Signatu Month Day Year <br />I (2 I 3) <br />EPA Form 87 - 2 (Rev. 12-17) Previous editions are obsolete. DESIGNATED FACILITY s e-