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02-15-17;07:56 ; 812094683433 # 1/ 3 <br /> Please print or type,(Form deAW for use on et •-*h)"turitsr.) - Form Approved.OMS No.2050-1639 <br /> UNIFORM HAZARDOUS 1'urn 10 N(enbm 2.Fe—ge 1 of 3,Emargmcy Phone 4. an Tracklrv" or ` <br /> WASTE MANIFEST A D `�g j 4 5 g 9 q� j, 5 v®.Y�,H, -/.Toc� U> <br /> � <br /> 5.Gaheratot'e Nam@ aril Mailing NngAddrew G- ww%SItcA�tresa different Von meilrmg address) <br /> 51v51R 12-pat.1,-4/ G¢, <br /> cotioraittof Phone; I13k ,V k ?xM o,, G $ Na$99g. ZAIfi- S 7'o G -roti Z-o 6 <br /> e.Importer 1 Company Nemo U.S.EPA ID Ntaa�r <br /> ll�►ri 1 TG:i,�t1R:. _ nErnaixaCe A R 0 0 0 2 1 7 5 1 3 <br /> T.Tranaporlef 2 Company Neme <br /> U.5,EPA 10 Number <br /> 8.Dtrsignated F fVama and S'daAddressAH 25 2016 U.S.EPA IQ Number <br /> FKK R ,OTC. <br /> 1410w. nue <br /> Mmwrqlon CA'U316 ENVIRONMENTAL <br /> Fadli ft Phone:909 •A21-2012 UCAITH-DE •I TMEINT >C= g p 0 8 2 4 $ 1 <br /> 9a, 9b.11.5,DOT Description#Wtdng proper Shipping Name,Hazard Clam,ID Numtror, 10.containers 11.Total 12.Hm unit 18.Waste Codes <br /> Paddng Group Vary)) No. Type Quantity W lvol. <br /> 1'NO� �L�A �tq-��Tz.(�G+�S ��..-a�r�r� .so��� I b O C? 35 7,. <br /> Pot Draxyu <br /> 2. <br /> 3. <br /> r <br /> 4. <br /> P.Sp R-Handkig•tndmrdiorrs andAdditional mf lion <br /> I'J04M 6867 <br /> 1$. MERAT(hTstoFFEROR's CERTIFICATION:1 hereby declare that the contents of Ibis mr aignm M aro f*and acouretely described afwve by the proper�dpping name,and are dasaified,ped(oged, <br /> marked and labeled/placarded,and are in all respects h proper condition far frw0W KeWIN to applimbla bdematlanaf and national governmental regulations.I export shipment and I am the Primary <br /> >;xpo*-1'0*that the contents of fibs Consignment conform to the(emus of the attached EPA mart of Consent. <br /> I.caf ify ihat the waste Nnimtxarkm staternard Identified In 40 CPR 292.27(x)(I I amp large quanbly g rstor)or(b)(til con a smal quantity generak4 Is(me, <br /> Cpm,eraiar'SfOflerotsPrinted/TypedName fgnak>ra Manch Day oar <br /> ..r <br /> it imemafion <br /> rpments ❑bnport to U's, El Export from U.S. Port of entryle)dt; <br /> 7ranspodar signature{fa exports aVy): Hate leaving US.; <br /> f' � 'd7.TranaporlerACkttoMll@e�r„ar,t�Rar�iptofAta�rials <br /> r d^ Transperltx Pr6stadrTyped Name Signature Month Day Year <br /> FbtLci <br /> Tumspbrier 2 Pdrdedrfyped Nara tura Manch Day Year <br /> 18.Discrepancy <br /> 18a,Diasmpancy Indication Space ❑ Qum ❑Type Residue ❑Pertiar Rojectim ❑FuI Rejection <br /> Msnifaat Reference N(Knbot; <br /> �3y 18b.Altamata Facility(or(�Pniti, r) U.S.EPA ID Number <br /> Fa(dq�s Phone: <br /> LU <br /> 18c,51gnatlxeafAtlemale,FadTly(of Gonarator) Month Day Year <br /> 19.Hazardous v6sto Report Managemem Method Codes p,e.,codes for hazardarm waste treatment,dl poral end recyc9ng aymems) <br /> 21.Dasigneted Faddy ftor or Operator.Cemtifiranlon of Moot of haze*ua rnatedats m"rod by the manfteat except as nsted f l Item 1&j <br /> PrfntadiT amoSvoture LAW Day Year <br /> :PA Form 87M22(Rev.3-05) Previous editions ars obsolete. DESIGNATED FACILITY TO DESTINATION STA'T'E(IF REQUIRED) <br />