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X1783 Form Approved.OMS No.2050 0035 <br /> Please dint or type.(Farm designed for use on elite(12-pitch)typewriter.) <br /> 1.Generator 1D Number 2.Page t of I Emergency Response Phone 4.Manifest Tracking <br /> Number <br /> UNIFORM HA7ARDOU5 I 7.�i`3f' OO O 1 C, O DAT <br /> WASTE MANIFEST � 7;) 577—"? � ' <br /> 5 (;eneratads Name and Mailing Address Generator's Site Address(if different than mailing address) <br /> -I�� F�I6E(T IC <br /> 1Sk X110 I_ajlsitiFcS Frei�llt. In. <br /> T 51,15 S. AiRMT VAT <br /> 505 S. AI <br /> Gen �rs phone: U.S.EPA ID Number <br /> S rnrgerter 1 company Name <br /> Name U.S.EPA ID Number <br /> T.Transporter 2 Comany y <br /> ' S.Designated Facility Name and SRO Address U.S.EPA ID Number[ Mfts RL i 7 <br /> OF EM, LLC <br /> NNLVkft Drive fast <br /> Name,Hazard Class,ID Number, 10,Containers 11.Total 12.Unit <br /> 9b,U S DDT Description(indurbng Proper Sftipp=n9 13.Waste Cades <br /> s .1'IA1 <br /> and Paddng Group(r€any)) No. Type Quantity Wt.Not. <br /> Ur LM <br /> HIM G7. <br /> Mt <br /> D <br /> and Additional Information '� <br /> . <br /> { ``1gyp w E <br /> 6ji SOL t M • Y l <br /> declare#mt dwaK <br /> the conte of this consignment are fuh and army descnbed by the P�ahrppG�.f�rte,and are dasusufled,pa <br /> andare in an&Sped% port=tdilion for transaccording to applicable inWTk tional and national goverrtmentai regulations.if effort slrpment and I am the PrImary <br /> Ifrat tti9 contant,of fills t o*rm to tits terms of tha attached EPA kknowledrgnent of Consent. <br />,- '' m;r,etlaatiOn�(atement idantffied in did CFR 2t92.27(a)[if I am a WV&quantity gener r)Or(b)(91 am a swan quantity go-ralor)is true. <br /> .. MA <br /> f4ame 3 , yiear <br /> ❑Import to U.S_ ❑Export froon Us. Portof entryl-a <br /> Date Ieaviny U.S: <br /> dfieceiyt of MtdEriafs <br /> Signature 1 Day ybar <br /> 1.4 i <br /> Signature MorAh Day Year <br /> 18a. ❑ Qtrantity ❑Type ❑Residue ❑Penial Rejection ❑Full Rejection <br /> Manifest Reference Number: <br /> 18b.AHe�e�.Pac�ity(ot Gerleral�') U.S.EPA fD Number <br /> Fad loltpnec Month Day Year <br /> 1 y.L f Attemsla auTity(or Generator) <br /> ?f <br /> 19 liar s Ianagement Amthod Codes(.e.,cis for hazardous waste treatment,disposal,and recycling Systems) <br /> 2 4. <br /> 120.Desig d F• ovo. or tor.Certification Of receipt of hazardous materials amrsd by the marrifest except as r#ed in hem 16a <br /> P€intedlfl'P� <br /> ignature tis Day Year <br /> Name <br /> EPA FtMn 870St• '.'per <br /> PMVkKrs editions are obsolete. DESIGNATED FACILITY TO DE STINATIO STATE(IF REQUIRED) <br />