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print or pe.(Form designed for use on elite(12-pitch)typewriter.) Form Approved,OMB No,2050-0039 <br /> 1.Generator ID Number 2,Pae 1 of 3.Emergency Response Phone 4.Manifest Tracking Number <br /> u <br /> WASTE M NIFORO N Fu$EST (_ ( 7 g O°w"`i r- .' 3 4 8 9 JJK <br /> J� <br /> 5,Generators Name and Mailing Address + � , .,�` f' Generator's Site Address(if different than mailing address) <br /> -41 <br /> Generators Phone: <br /> 6.Transpoler 1 Company Namery))���f U.S-EPA ID Number <br /> FRE,,kI XM EP VtN(3t�li4FWAL S{CR ICE1INC F'twvwt*W)55€f-'1774 C AR_lfitii l,'101•" <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> 8.Designated Facitity Name and Site Address Z 1 ST CENWRY EN U.S.EPA ID Number <br /> 2t}3rY.9I�E1fVl.1AMS DRIVE, FAST <br /> if1lt�Zti)$c+'j :ki <br /> FFRNL Y,W 8&W8 <br /> Facilitys Phone: <br /> 98 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11,Total 12.Unit 11 Waste Codes <br /> HM and Packing Group Id any)) No. Type Quantity Wt./Vol. <br /> 0 / <br /> LU <br /> 3. t <br /> I <br /> i <br /> 4. <br /> 14.Special Handling Instructions and Additional Informabon <br /> li arwftm to ben 0liw trmn-ed anal une Pf'L. <br /> i!1t:`1h -18d1f&9-4X) L RG M 171 <br /> t�, -a , l'1 1-_ r--,/—) <br /> 15. GENERA7'ORINOFFEROR"S CERTIF1CAtION: I hereby declare that the contents of this consignment are fully and accurately described above by the proper shipping name,and are classified,packaged, <br /> marked and labeledlpfacarded,and are in all respects in proper oonditon for transport according to applicable international and national govemmentat regulations.If export shipment and I am the Primary <br /> Expoter,I ov*that the contents of this consignment conform to the terns of the attached EPAAcknowiedgment of Consent. <br /> certify that the waste rrwrwmization statement identibed in 40 CFR 262.27(x)(if I am a large quantity generator)or(b)(if I am a small quantity generator)is We, <br /> G eratoeslOfferoes?rinlodlTyped Name Signature Month Day Year <br /> I <br /> . <br /> j 116.International Shipments <br /> 2 1-1Importto U.S. ❑Export from U.S. Port of entrylexit: <br /> Transporter signature(for exports only) Date ieaving U.S.: <br /> UW 17.Transporter Acknowledgment of Receipt of Materials <br /> er 1 Print ped ame IZyra re Month Day Year <br /> a' Transpbder 2 Pnnted7Typed Name Signature Month ay Year <br /> t- <br /> 18.Discrepancy fF �t <br /> 18a-Discrepancy Indication Space E:1Quantity ElType 0 Residue ❑Patel Rejection ❑Full Rejection <br /> Manifest Reference Number: <br /> 18b.Alternate FarAity,(or Generator) U.S.EPA ID Number <br /> J <br /> V <br /> LL Facility's Phone: <br /> qW 1 ac.Signature ofAltemale Faality(o Generator) Month Day Year <br /> Z <br /> 19.Hazardous Waste Report Management Me tod Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> 20.Designated Facility Owner or Operator.Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a <br /> Prinledffyped Name Signature Morth Day Year <br /> EPA Form 87DO-22(Rev.3-05) Previous editions are obsolete. GENERATOR'S INITIAL COPY <br />