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PIeQs+ pfU+Yo�'3y xe. pam.4agi vied tar use on e(He {12• Itch I er.} <br />Form A roved, OMB No.,205t140 <br />toonamtotio Number <br />-MTU <br />Paget of <br />3. Emergency Response Phone <br />-Mr <br />1. n ! ck NumbsIFOR�iNA�ARD0U8 <br />WA87E MANIFHST !W. <br />12; <br />'� <br />°A. '"d <br />d ; Fl; <br />GenMr vs Name andp�ofiiyrep dr e <br />���p era o a rasa (if ' f!FW <br />Lid <br />49 <br />. s <br />n me addoBse) ,r <br />F <br />,} q t <br />C�lYaret0?8 PhOne <br />15. Ira �perar- CanDaOY e <br />i �i 11M119k.�1: S7Q11'Qi1. �Eo`111� <br />I Nu'rlher <br />Q <br />4�. @narler mpeny eme �. <br />U.S. EPA ID Number <br />' •,;r <br />cl b a e a <br />' �. �tl1t#7� <br />U.S. EPA ID Number <br />reijaytuyrr�li�niyy <br />.d <br />�:�P�tlili <br />- <br />I lei <br />'s.pfxxte: <br />• <br />Fadll <br />HM <br />9h.'U:S. DOT Description (including Proper Shoping Nome, Hazard Clan, ID t�rtrtber, <br />Packing ; <br />10. Contalnera <br />19 WaetaOldies. <br />endOr*(if ay}) <br />W. <br />Type <br />Quardity' <br />,WtJVbh'.',.' <br />lumidow wage 510M MY bdif" <br />1. <br />.. - <br />;Hs : p <br />.. <br />r• <br />- <br />14. ne Iona Informs den <br />iYddfY RkeratrfllTewrk� <br />�i'y a0'4rf9Klr-rW. `,\� `�� ..__ �'//�'• `(+_� �\+''' ��'jf�''y <br />- . '1.. <br />16' GENERATOR'ddOFFFRORS'CERTIFICATION:Ihwvbydeclare that the contents ofINS co�igrmenterelWyand s=mtdydaecribedabove lbyIN roper shipping rre*.and iilll <br />'.'marked and tebeledJpiacartled, and are In all respects In proper condition for transport according Io spoldecle Internaliwol and neticnal governmental r0gilatloms, Hexport shipmemtw trlilt iePF�jrp :t :' s; <br />Exporter• l cerltfy the contends of lh4s conelgnment cort`orm to ilia Isrin .of the attodW EPAAcImWedgment of Consent. _ <br />I.cerldy yvat the midmiza8on Bteiemenl ider IRM in 4O CFR 282.27(a) (H I em a large quantlty genewtor) or @) (H e swill quanlltygenerator)fa We. <br />era rorB n Nine <br />4 <br />ntemaibnal. <br />Impatto U S. I_J Export from U.S. Port ole inwoxil: <br />hens e! mere for ords'anl oatleau U.S.: <br />17. TtatiSsM*-Ackwwledpnxx I d Receipt d <br />P <br />i A: <br />AJ7 Vg ork I <br />AM <br />ranepotkr n e me gn ure <br />r, <br />.•s <br />1S. decreparay - <br />• <br />1ea.'n®aapancy iridkatton tdlpgoe G.J - ❑ Type D Raddue <br />I�1� <br />Ofedfei M1010d e . `C Fril <br />Men <br />, � <br />18b.Ahrtmb:Feaply{aGeneratgt) <br />U:S..E ID41taNGdlr �:_- <br />Facl a Phone: <br />1" , P' <br />' � <br />c. Igna'hreofNtemateFecllNy(w aneratar), <br />: - , <br />I Ifni <br />19. Haiardous 4Yesle Report Manegainent Mehod Codes {Ge., codes for hazardous waste treatment, disposal, and recycling systems} <br />W r tr ,. <br />1. 1 <br />2 3, <br />0 <br />20. Designsted Facility Owner or Operator CWillcatlon of recelpt of huardoin malarlals covered by the manliest except as rested In I>Qm <br />PrintB ed Norma gnalure f r r <br />PA Form 870022 5) Prividow editllme are obsolete. <br />DFAGIi Y lLTO Of <br />ESIGNATED iA <br />�f'rrf.ti..e'''. ,ti '"^+ .4s • •'� .... .. `�... .,.-,. .. :-.?t_ii.....L':'.:.._,.... r ,.-,....A,...i ry h..•6dp.�l. ..^m.!?.. <br />