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print or fypa.(Form casigned fol use on e,Te 0 2-plt:h)MXWOV Form Approved.OMB No,2050-0039 <br /> Zpagell 3.Em 4 Manifat Trickling Number UNIFORM�HAZARDOUS�IG. y Phons <br /> wasur ID Nimber SKS <br /> WASTE MANIFIEST, <br /> Generator's Piona U.S.EPA 10 Nunnzer <br /> 6.TiersP.orter1rom,ne Nam <br /> TTranswrib,2CimpwiyN9mQ U.S.EPAID Number <br /> S,Desigreled FacdilyNaessaaMSileAddreaS L.S.ERAIDNumber <br /> Facts <br /> Sa Sb.US.DOT DW-001 Ocladhg Proper Shlanng Name,Hazard Glass,10 Nunben, 10.CanTirerrs Tires 12.Ult 13.Waste Codes <br /> HW and paddrg Gmuip:lfany)) No. Type Quatalty M1401. <br /> 0 <br /> z <br /> 3. <br /> 4 <br /> 7 <br /> 14.Special Peamping lwrwcJDns anc Adalftnal.nformstOn 1- <br /> i6 GENEFAICIR'SIDFFEROR'S CERTIFICATIoR.I mrcy us,o,m inwitas=Was of this consigraneml we fullyard ac=rately desco'hW zboviaby ft proper sitipringracree,aid as classifuml,packaged, <br /> marked alliabeled1pocauced,and am In al respecls in proper conCOM for Transport KMfdiV to acpliable merrailonalard agarol gmenamental regulators Ifexpar sh;pmepond lam the Niamey <br /> of tairtaclied ElAklanoidedgmentolOonsert. <br /> I ca&y tat the wasteminiffiallon statement idurfiffied a 40 CFR2C2r(w(fl am slarge prentrV ganvaloo or(1b)Ofl was small cpanttygenwwar;jshue. <br /> GenwMo`V6F6&_9PnrdwVryped Name cgnw... Month Day Year <br /> 16 lWarnalloval <br /> Lj Import W US ElEvnid rice-u.s. Pad of e1byJak. <br /> xiyy Dalin leaving U.S,: <br /> W 17,Trusponer kWoWedgriend of Recalipt T,Materials <br /> 112 Mont Day Year <br /> rmbeapme,I_Pnr1.d'TAxd Nal- Signature <br /> Day VEM <br /> C <br /> I18.Discrepancy <br /> IS&Dscrecanoy Indicator Space ❑ Quartity [:]Type Ll Rezid,e ❑Pallial Rejection ❑FA Rejector <br /> Manifest Reference Nt,rnbar <br /> : 18b.Alternate Facilly(a GaMAW U.S EPA 0 limber <br /> zi <br /> FaJ11V3 Pitons. <br /> 0 <br /> ej Mmtn Day Yea- <br /> otAWjwE Facilfty(crGenerator) <br /> Z <br /> 0 19.Havamou5irlaste f;epzft bleawranat Matted Codes(1.0.,modes for hasordicauswesta haswalent daMsa,and racycing systems) A <br /> 2. <br /> Zj.Deigawd Fwdjjy C,,,vq Operator.CertilGado-,dwricibi'wzardoz talefials ocia,'ed by the armilest ampt as Wed h item'.as <br /> atedfTypWNsMD $gave W-111 Day <br /> Year <br /> EPAFornI87CO-22(Rer?'3-05) Pravicus editiorrs are obsolete, ., CENEIR—A MRS iMTIAL COPY <br /> Z'd 699L-9C9-60Z `S4SP19Ajje91V P-69:90'L L OC d98 <br />