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ease print or type. <br /> UNIFORM HAZARDOUS 1.Generator ID Number Form Approved.OMB No.2050-0039 <br /> WASTE MANIFEST �"��� 2.Page 1 of 3.Emergency Response Phone 4.Manifest Tracking Number <br /> 5,Generator's Name and Mailing Address 31 507 8 & i2-9s : l <br /> 6s 025963491 JJ K <br /> Aft MoftiftR%"MfV Generator's Site Address('d different than mailing address) <br /> �U g33i��i1133 Tmrtfnw <br /> --— --- --- StaLk43203 <br /> Generator's Phone: <br /> 6.Transporter 1 Company Name <br /> U.S.EPA ID Number <br /> P"dar EtriAffim CAR00107 80 73 7 <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> 8.Designated Facility Name and Site Address U.S.EPA ID Number <br /> & h <br /> 1630W171h5L <br /> e_V1 ky 4�1p a,w A'km■0 r a n n a as n <br /> Facility's Phbne: ar n n ar. <br /> ga_ 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit 13,Waste Codes <br /> HM and Packing Group(if any)) No Type Quantity Wt.Nol. <br /> 1. Rte:LM M. ►OW&Ia,mo.r,[H meet <br /> 1114 3xPGNow,Do t <br /> w <br /> Z 2. <br /> W <br /> co <br /> 3. <br /> 4. <br /> 14.Special Handling Instructions and Additional Information <br /> 1) VM022746 PWWO011669 9!QMft&dsMv'CWD <br /> 15. <br /> GENE <br /> CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by the proper shipping name,and are classified,pa&a <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 Prime <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)(if I am a small quantity generator)is true. <br /> Month Day <br /> Generator's/Offeroes Printed/Typed Name Signature <br /> j 16.International Shipments <br />_ ❑Import to U.S. ❑Export from U.S. Port of entry/exit. <br /> Transporter signature(for exports only): Date leaving U.S.: <br /> C 17.Transporter Acknowledgment of Receipt of Materials <br /> Trans r 1 Printed/Typed Name Signature Month C <br /> Transp rter2Printed/TypedName Signature" Month <br /> 18,Discrepancy <br /> 18a,Discrepancy Indication Space � Quantity ❑Type ❑Residue ❑Partial Rejection O FI <br /> 18b,Alternate Facility(or Generator) <br /> Manifest Reference Number: <br /> U.S.EPA ID Number <br /> acility's Phone: <br />!C,Signature ofAlternate Facility(or Generator) <br /> Month <br /> Hazardous Waste Report Management Method Codes(Le,,codes for hazardous waste treatment dienn"I , a <br />