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' lease prfn or type.(Form designed fpr use on."elite 12- tch)typewriter. Form Approved.pMB No.2050-0039 <br /> UNIFORM HALIRpOtJ$ 1tXrCV6,269,7,, <br /> r 2,Page 1 of Emergency Response Phone ,Manliest TratkinB Number <br /> WAST15 MANIFEST '4 <br /> S.Generators Nam Address fJ `:� - .W <br /> 2, 0 96GBF <br /> Generelnr+s'Slte Address(if dltterant than mailing address) <br /> C�enerme 6rW one, <br /> ieDmpany Nam7. <br /> e <br /> z: <br /> 77rarrspbdw Company Name >U.S;EPAIpTJumher <br /> tis. 4 <br /> &De ignaled Faealry,Name,and SJteAddress U.S.EPA ID Nuhrber,. V <br /> Cf�{ '�e'£f'!ir•G1Fil>ti�t�i7r➢tom'{ns; ��� ����� #,g <br /> Facrh sPitfd{{i+,W54" <br /> ga, 9b.U.S:DOT-Dasa PWn(inclUding ProperShfppl4g Nama,Hazard Claw,ID NUmDer, 10.Containers 11.Total '12.Unit <br /> HM and Packing-0,10W.01 any)) , No.. Type Ouahlity WI.Nol. 13.Waste Codes <br /> d . <br /> Has'Waste, ofict2" <br /> w <br /> ' Your <br /> CERTIFICATE <br /> OF RECYCLING <br /> 41 <br /> By r- �:1318wll <br /> M <br /> 14 SperaatHaritlling.lnelruaGonsand AddltldnallnfarmaWn. <br /> Wra�r �s �%tiv� �t+ftt �► ar>t yevlr�ai: ,j -•011.-Y};tLMRBEN <br /> 15, ,GENERATOR'SioFFrROR'S CERTIF[CATrON: I hereby.tladare that the wn1en18 of this consigrmsant are fully and sp;uratei cIaacdl ; ebpve by the proper stopping name,erd are daseified,packaged, <br /> marNad and labeldlpiacarded,and are in all respects in proper candillpn fortranaport a=rding to applicable k Aftm ianal''and nalianai governmental M911180ons_If export shipment and I am the Primary <br /> Exporter,I cebty that the'contents or This mm�fgnmerd mnform to the leans of the elladrM EPAAcknoWedgmenterConmt <br /> 1 certify that the waste minimization statsmenl identitisd in 40 CFR 282.27(a)(if I am a large quentity generator)or(b)(ill am a small quanlJry,generatol)is Irue, <br /> Gencrabor'40heror's Prinled/Typ Name ignalure <br /> Month Day Year <br /> ... ^^r <br /> Ti,Intematrcn111 Shipje, ii <br /> f <br /> ments t—� <br /> ❑E1 <br /> ❑Import to U,S. xportfrom i U.S. Pori of entryeAu <br /> a Tranapoflersignalure(for expert portly): <br /> Dale leatirng U.S.- <br /> w 17..TransporterACknowledgmentofReceipt orMalEdals <br /> .rr,Tran F1 1 Vnnlgdfryped Names- <br /> y <br /> ! ,.. a Year <br /> IL <br /> Transporter 2 Pdnte yped Name <br /> S slure r`s d <br /> ' Month Day -Year <br /> 18.Discrepancy <br /> 18a.Discrepa"Indication Space <br /> ❑Qusnay ❑Type ❑R9sidue ❑Partial Rejection ❑Fu t Rejection <br /> •186.gllemate Facillry(©r Generator) Manifest Referenhe Number' <br /> V . <br /> ta+. facility's Phone; <br /> 18, <br /> Slgnalure of gllsmale Facility(or Generator) <br /> _ Month Day Year <br /> 19.Hazar jaua Waste Report Management McF*d Codes(Le.,oodss'IW 11atard0U3 Waste treatmenl,disposal,and re <br /> cydkrg systema), <br /> 2. <br /> 4. <br /> 20.Designated Facility Owner or Operator:CerftaUon of reoaipt of hazardous mated is oovarad by the maryfest ax rd-ed- item 18a <br /> Frint9dfrype Name <br /> Month Day gar <br /> E11A Form 8700-22(,Rev.$-05)'Previnu4 01110 are o*lete. .... I-77 1 f� <br /> 9 d 96SO "N WdZ Zl 800Z des <br />