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Farm Aaorovad. OMB No. 2050-0039 <br />EPA Form 87UG-22 (Kev. 3-05) linevious eamons; are oosoisre. I FVA1V0rVM I r -FN Q VVr I <br />UNIFORM HAZARDOUS <br />1 1. Generator ID Number <br />2 Pap I of <br />3 Ernergency Response Phone <br />14.0 n1festTracklig"blir <br />FLE <br />WASTE MANIFEST <br />4A <br />' <br />24 <br />—5. Generators Name and Melling Address GenerWhIts Addi 1 than wiling addrM) <br />Tw.y <br />411:0 UU111a <br />6. Transponer i CoffilpAft) a a U.S. EPA ID Number <br />1416 4117 (h. J. �i <br />1141 -wo.�Vj CAN 0 <br />.Transporter 2 Company Name U.S. EPA ID Number <br />8. Designated Facility Name and Site Address U.S. EPA ID Number <br />4 <br />I'V t'Av; ov�-�Ay <br />FsclWsNone: <br />ga. <br />9b. U.S. DOT Description (including Proper Shipping Name, Hazard Class, 0 Number, <br />10. containers <br />11. Total <br />12. Unit <br />13. Waste Codes <br />No, <br />Type <br />Hhl <br />and Packing Group (if any)) <br />Quantity <br />Wt.Nol. <br />oc <br />'q <br />t!K1 Wk. 't"'Ahjs' <br />all <br />4. <br />14. Special Flarxillng Instructions and Additional Information <br />Q, <br />47f.11 A-11 OV <br />J <br />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 />15. GENERATOR'SIOFFEROR'S <br />marked and labeltd1placarded, and are in all respects in proper condMon for transport according to applicable International and national governmental regulations. ff export shipment and I am the Primary <br />Exporter, I certily, 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 28227(a) (11 am a large quantity generator) or (b) Of I am a small quantlb/ generator) is true. <br />GeMonth U Y <br />-ralloes/Oftror's Pd d(Typed Name Signature ne <br />I B. International Shilpmentsrnport to U.S. El Export from U.S- Port of entrylexit <br />Transporter signature or exports onlDate leavinu U.S.: <br />- <br />17, Transporter Acknowledgment of Receipt of Materials <br />T0eran over 1 no!typed Name Signalurej th Y egr <br />4 <br />;;1! <br />Transporter 2 ProtedifTyped Name na a Day Year <br />18. Discrepancy <br />18a. Discrepancy Indication Space El Quantity ❑ Type ❑ Residue ❑ Partial Pj.'rion El Full Rejection <br />Manifest Reference Number: <br />'I ft Alternate Facility (or Generator) U.S. EPA 10 ISILimber <br />u- <br />UP 0 8 201� <br />Fadlity's Phone: <br />18c, Signature of Alternate Facility (or Generator) Month Day Year <br />2 <br />'W1 JI1111 <br />19. Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste treatment, disposal, and recycling systems) L- <br />20, Designated Facility Owner or Operator: Certification of receipt of hazardous materlals covered by the manifest except as noted in Item 18a <br />Month Day <br />PrIntediTypeo R.ame Signature Year <br />EPA Form 87UG-22 (Kev. 3-05) linevious eamons; are oosoisre. I FVA1V0rVM I r -FN Q VVr I <br />