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rn,. — I— rE„ .., A-,;---,4 r„ A;+- 140 n3nk%+--,A+., 1 <br />Fnrm Annmved_ OMB No. 2050-0039 <br />EPA Form tt/UU-22 (Kev. 3-0) rrevlous eamons are ousorere. ry uv�i <br />UNIFORM HAZARDOUS <br />1. Generator ID Number <br />2. Page 1 of <br />3. Emergency Response Phone <br />4, Manifest Tracking Nu <br />" <br />0 FLE <br />WASTE MANIFEST <br />. iii Y! " '. `r <br />I <br />i ! ,,;;., <br />•' �. 4. SJ A.i +m- Ar- <br />5. Generators Name and Mailing Address Generators Site Address (if different than mailing address) <br />fry iofjld3tkt OBA StmM.C41 L.6�;1,�vfkhi�g LLC <br />::�tLA• i :� f°;1 i52lO6 <br />Generator's Phone: w .?7, i <br />6. Transporter 1 Company NameU.S. EPA ID Number <br />ryIf.1"A (Sj <br />7. Transporter 2 Company Name U S. EPA ID Number <br />8. Designated Facility Name and SiteAddress US EPA ID Number <br />PO BVX at it iw- 96,1i I�� 45 S Bee -A1v <br />8,90 IX,W4 =3 <br />Facility's in. <br />ga <br />9b. U.S. DOT Description (including Proper Shipping Name, Hazard Class, ID Number, <br />10. Containers <br />11. Total <br />12. Unit <br />13. Waste Codes <br />No <br />Type <br />HM <br />and Packing Group (if any)) <br />Quandt y <br />WLNoI. <br />ssftei Paas. a , PC, <br />o <br />l; <br />UJ <br />z i ,i9, C•t�tr nsive adds, MOS, (`: slfitm 1110170kh1e). 8, FIC <br />?? 9 i <br />`` <br />a:.ion-F:CRA fl,tr.a -dotrs Woo, Uquid IS IRF.At: i'AN'D <br />4. <br />j <br />_r <br />14. Special Handling Instructions and Additional Information <br />OAM wit Y. <br />15. GENERATOR'S/OFFEROR'S CERTIFICATION: 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 labeled/placarded, and are in all respects in proper condition for transport according to applicable international and national governmental regulations. If export shipment and I am the Primary <br />Exporter, I certify that the contents of this consignment conform to the terms of the attached EPA Acknowledgment of Consent. <br />I certify that the waste minimization statement Identified in 40 CFR 262.27(a) (if I am a large quantity generator) or (b) (if I am a small quantity generator) is true. <br />neratoeslOfferoes Printecirrype Name igna ureMonthay_ Y. <br />r' <br />-J <br />16. International Shipments <br />❑ Import to U.S. ❑ Export from U.S. Port of entry/exit: <br />F- <br />?Date <br />Transporter signature (for exports only): leaving U.S.: <br />W <br />17. Transporter Acknowledgment of Receipt of Materials A <br />a.'i"i' <br />a� <br />Transporter 1 rintedlTyped Name j Signature/ ' j r on` 1 t ear <br />•4 <br />. �4,.� ?'-I r r:{',1 C�� to ir. i 1._i.� "a" ,. .E ..,v."> IC4 <br />Q <br />Transporter 2 Pdnted/fyped Name Signature V onth ay year <br />a' <br />F- <br />18. Discrepancy <br />18a. Discrepancy Indication Space ❑ Quantity ❑ Type ❑ Residue ❑ Partial Rejection ❑ Full Rejection <br />Manifest Reference Number: <br />18b. Altemate Facility (or Generator) U.S. EPA ID imbir �- �,: , 1w, k <br />J <br />U <br />LL <br />Facili sPhone: <br />C3 <br />18c. Signature of Alternate Facility (or Generator) Month Day Year <br />Z <br />N <br />L_ a <br />19. Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste treatment, disposal, and recycling systems) e r r u nr-m <br />0 <br />1 <br />2.3• <br />4. <br />20. Designated Facility Owner or Operator: Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a <br />Printed/Typed Name Signature Month Day Year <br />EPA Form tt/UU-22 (Kev. 3-0) rrevlous eamons are ousorere. ry uv�i <br />