|
Please print or type,(Form designed for use on elite(124ilch)typewriler.) Form Approved.OMB No.2050-0039
<br /> UNIFORM HAZARDOUS 1.Generator 10 Number 2.Page 1 of 3.Emergency Response Phone 4.Manifestt�Tracking Number
<br /> WASTE MANIFEST :R�443�Jf} ?7 ?`1f i '1 t' ! . SKS
<br /> 6,Genaparoes Nam and Maling Address Generator's S'ileAddress(If dltfe+ent than mating address)
<br /> st':S.is lois
<br /> Generatoesphone:
<br /> 6.Trarfsporter iComoanyName U.S.EPA ID Number 7 X Rn ,r,+ut+'+'ir?
<br /> 7.7Yansporterccomwy Name U.S.EPA iD Nunthar
<br /> 8,Designated Fadity Name and SiteAddress SAT,E n—*i J'-.t'F( S y tr'+w n5 i �y f r^. (4.y='i,!,r', U.S.EPA I0 Number
<br /> SKRAVDITO
<br /> FWI S Phone:
<br /> gi, 9b,U.S.DDT UemVlion(mcluditg Proper Shipping Name.Hazard Clan',ID Numbef, 10.Containers 11,Total 12.Unit
<br /> HM and Packing Group(many)) No. Type Ctonlity WIJV01, 13Waste Codes
<br /> .
<br /> FAVI RELATU MA'f'ERIN-P 2,, U141261 r s , 2 .• ;' 4;r:� )'Q{, r�r�
<br /> D0111-4 Dons
<br /> iu
<br /> � r
<br /> a
<br /> 14.Specal Handing Instructions and Additional Information r + j ,i 1741
<br /> G Kr f i'S'.
<br /> • e 1 L_�+. 91
<br /> Ij q 'r-.x*SV Stl ?4 tF F wAf- l`aRS .A5 Rc:CF.S;a!2` Y
<br /> 15. GEN ERATOR'S10FFER0R'S CERTIFICATION: I hereby declare that the contents of this oonalgnmert are fully and acauetdy described above by the proper shipping name,and are classified,packaged,
<br /> marked and labelsdfpfacarded,and are in all respects In proper condition for Imospod according to applicable internylipnal and national governmental regulations.if export shipment and I am the Primary
<br /> Ekporter,I cert that the contents of this consignment conform to Ihn terms of the attached EPA Acknowledgmenl of Consenl.
<br /> certify that the waste minimization statement idw0ed in 40 CFR 26227(a)(if I am a largo quantity generator}or(b)(ill am a smell quantity generator)is true,
<br /> GBnArat.r'slOtfer.rs Printedfryppd Name t! $ignalure :;' /'//�' Month Day Year
<br /> --i 16.International Shipments
<br /> F ❑Import!.U.S. ❑Export Hom U.S. Port of entrylexit
<br /> T ransporl er signature(for exports only): Date leaving U,S„
<br /> LU 17.Transporter Ar mledgmentofRoceiptofMatetials
<br /> a Tfansporler,bPrintedlTyped Name f s ! S#yAahtre.. Mo ih Day Year
<br /> ,l n- '' „1'a ��•. t' ,'M:/ r,,�,,,r�t'r' r i. ( �. ; a� r
<br /> f
<br /> 4 Trangp. r?NnitrdlT afdH o, Monthr Day Year
<br /> 18,Discrepancy
<br /> i8a,Discrepancy 106calion Space Quen ly ❑Type ❑Residue ❑Partici Re,W, L I Full Rejeclinn
<br /> Manifest Reference Number
<br /> I8b.Allemale Far*ly(v Generatw) U.S,EPA ID Number
<br /> CS
<br /> F3cilitya Phone:
<br /> w 18c.Signature of A]temsle Facility(or Gcnerator) [Month Day Ye a;
<br /> 19,Hazardous Waste Report.Management Method Codes(I.e.,codes for trazardouswaste treatment,disposal,and recycling systems)
<br /> O 1. .; .,1 2. �, 4,
<br /> 20.Designated Faalily Owner or Operator:Cedification of receipt of hazardous malarials covered by the manifest except as notop in Item i sa
<br /> Printedfiyped f a ff f ff g S`igrl�+fB 1 ,;r' !, ''•'/ Month Day Year
<br /> y,�ll! ��t � �' '�'~J � / . "6`-' f` 1fCr r^' !�f•�.,#'%i' R f /'...r,- '' t�! ��� `
<br /> FPAFnrinA7 _)91Rav 215F1 Orevin,9enrf:r:nnce.onho..�oln n�nrn....Te-...•....., e�...�.r ..�..�...-..••,•, •,—._�•- ••�
<br /> 899-3 TZZ/310d 063-1 9TG�9889T6 ZZ ZT BT ,-BT-To
<br />
|