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SSL :'r, ;4;lGa� r.4;E;Q1.iYc�, <br /> Please print or type.(Form designed for use on elite(12-pilchwriter) Form Approved.OMB No.2050-0039 <br /> UNIFORM HAZARDOUS 1.Generator ID Number _.�r r. -. R 2.Paga1 of 3.Emgr ell Response Phone.. 4.M it(��t c ur�pp7e <br /> WASTE MANIFEST ..5.1L•v.. 7 '�k.'¢ - ,. . .. �VgV0 <br /> 5.GW i th FLE <br /> Groul) Inc rs Name and Mailing Address Generators Site Address(if different than mailing address) <br /> ix 0121E a a:'a I; n;.v<.V S � <br /> ftfP}?ONCPE f1 3'53t:f ,'•'r7? <br /> Generators Phone: - <br /> 6 TrensF?r Com any ame x <br /> -.F..'t:fY—'tQl,r. mn GY�r1 t. •ty, 3)'!G'. . .WAoer <br /> TX 011•"0,401 c,OF; <br /> 7.Transporter Company Name U.S.: IDNumber <br /> 8.Designated Facility Name and Site Address 1,1 �zl4r k;1RRI{(]i t, St,R J&� i U.S.EPA ID Number <br /> �e3'A t+F�.ifli/)"sSCt F(.i}la'7 . <br /> IAN J0 F 9,71 <br /> Facility's Phone: <br /> rift--441 1;,it _1 4.'•{17.'< <br /> ga. 9b.U.S.DOT Descdp8on(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11,Total R <br /> HM and Packing Group(if any)) No. Type Quantity 13.Wasm Codes;z:•W2. VION:, !Y N k( wfd Ht?ZORD[Ifli] WAR`,, Sic <br /> c� iEiBP v D3t(I14aF H!q <br /> 3. <br /> 4. <br /> 14.Special Handling Instructions and Additional Information 1 sk T n069180cj t,1 <br /> 4�r 9 7t::'vs s zk i' iifi(` <br /> filth CltIRRJER 1 PS NIFCESSARY 717111".91630ey <br /> 15. GENERATOR'SIOFFEROR'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 respect 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 terns of the attached EPAAcknowledgment 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 /> Generator erors Pnnte yped ameigna ure on ay Year <br /> �. is <br /> --r 16.Intemafional Shipments <br /> z ❑Import to U.S. ❑Export from U.S. Port of entry/exit: <br /> Transporter si nature for exports only): Date leavin U.S.: <br /> W 17.TransporterAcknuMedgment of Receipt of Materials <br /> Transporter 1 Pdntedfryped Name <br /> Signature _;- ' ort Day ear <br /> i Transorter2 Print r I _ I, <br /> • 7i <br /> a 0 edlfyped Name gnature v <br /> Of Month Day Year <br /> F <br /> } 18.Discrepancy <br /> 18a.Discrepancy indication Space ❑ Quantity ❑T a <br /> YP ❑Residue ❑Pallial Rejection El Fall Rejection <br /> Manifest Reference <br /> 18b.AlemNumber. <br /> ate Facility(or Generator) U.S.EPA ID Number <br /> J <br /> U <br /> a <br /> LL Fapli 's Phone: <br /> M 18c.Signature of Alternate Facility,.,Generetor? Month Day Year <br /> a <br /> Z <br /> y19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> 1 2. 3. <br /> 4. <br /> 1 20.Designated Facility Owneror Opera or.Certificatlono eeipt of hazardous materials covered by the manifest except as noted in Item 18a <br /> Printed/ryped Name Signature Month Day Year <br /> EPA Fom}�70,0-22dRe 3 05}PEevious-Aditions,ere obsolete �. <br /> o.. ,i ,i a- :..; GENERATOR'S INITIAL COPY <br />