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}; 'THIP# + y` 'r <br /> � (+ D 4697 '1363 KS <br /> Please print or type.i Form designed for use on elite(12-pi )typewriter) Fc m Approved.OMB No 2050 <br /> 1.Genimilur ID Number r,z,. 2.Pagel of 3. Rq�Ose"I' „ d.AlanifeI TraNumber <br /> UNIFORM H US ('t;);^FSS ).!Ifl4 1 1--:1laFT--i::•I I-1.,.,C� 00'4107136 , <br /> WASTE MA IFEST <br /> S.GemstalorsNare andlilmingAddmss Genemto/s Skentldress(d tlMeren(Mert mawrigawars� I <br /> GeneratafsP •-'l1!� [+•}yY rel-`. I <br /> CA <br /> U S.EPA it)Number <br /> 6.r rl: ?�yt Fy( r!.iy IN.,:. Rtt$: p,1 I@1 <br /> Y.Tmnspater 2 mparry Name U.S.EPA N Number <br /> 1 DealgratedF Ily Namaand VeAddress l IN, iPRBORS BUT I'AMWI!_LOWr : i C U.S.EI)l Number <br /> r0I 141tTRN ROAD <br /> POT Mill 01-1 t, CIA 13,11,71V-1 <br /> FedF'tys Phone: <br /> ga. 9b.U.S. T Des ,p Or(hidudirg Proper Slipping Jerrie,Hazard Class,ID Number. 10.Containers 11.rural 12.Unit 13.Wase Codes <br /> HM amP ng�(iI any <br /> No. Type Quantity WLNd. <br /> I,cc <br /> T 1-IL7, rLE- d', <br /> o Tf'Y rFk?hdTS}a Ni — <br /> I <br /> M z <br /> RE(;EIVF.0 Fj <br /> 3. <br /> JAN 2 Bl 2015 <br /> ENVIRONMMIAI <br /> a. <br /> HFd!TU r1CDd pT14GNPrL <br /> 14.Special Having1nsWctions and Additional lnlamalbn <br /> r - 41 !lplk", 4 - <br /> y ' Te Iref-•^-x - Ihc Ire r.pG <br /> 15. GENERAT 'SIOFFEROWS CERTIFICATIDN: I harE oy declare that the col of this cunslgnmenl aro fully and accurately described aGrve by the proper shipping name,and are tonsi pa dCa9ed <br /> marked and abehaNplacinced,and are to all respecis k proper curdlion for transport according bappFsdeiMemadorW and national gamrlmental negulaticres.If export shipment and l am the Primary <br /> Exporter,I orfily that the contents ofrhisoonsignment i wl to the wrinsoftFeattedled EPAAduwwledgnantd Consent. <br /> I certify that a waste ninmodeoo statement Identified in 40 CFR 262.27(a)(if I am a large quantity gera la)or(o)(dI am a small quavery generator)Is he <br /> eratolsr00e s PdntedRyped Name S5'terFe Monts Dsy <br /> / J _ <br /> ❑Import to U.S. ❑Export hon U.S. Porth aMrylexn7 <br /> z Trzrsporter sigv hire(for exports arty): Date lenvirlgUSll.,,- r ' <br /> Z 17-rarsoarekknowredgmerlM Receipt of Materials <br /> -raps e 1 Pn yped a Signature / Month. Day <br /> a _ <br /> Q Trartaponen 2 Ri IedRyped Name <br /> Signature A1pn71 Day <br /> ♦ 18 Discrepancy <br /> 18a,Disi Indication Space ❑ Qa,tlH ❑Type ❑Residue ❑',ha Rejection ❑Full Rel <br /> Manfest Reference Number: <br /> 18b.Mamate Fa tiffly(or Generator) US.EPA ID Number j <br /> V <br /> LL Fahy'Phone: <br /> w 18c§jna—ture 01 Alternate Fwltty la Generator! Month Day <br /> Q <br /> Z <br /> � !9.Hazardous s'e Report Menagenanl Method Codes(i ,caes'or hamNous waste treatment.deposal,and nal systems) i <br /> A 3. 4. <br /> 1. 7� 2. <br /> 20.Designated cilay 0e 11 r coacallon of is wpl of henrdous (buts coremo by Iremanifest ezcepl as rMed'�n Ilem 16a <br /> Pnntec/Typed N me . Si-1te; Mon <br /> - 19 <br /> EPA Forn B70C-22 Rev.3-05) Previous edition a re le. DESIGIJATED FACILITY TQ DES'i INATIQN STATE yIF RE t ) <br /> i <br />