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Please print or type.(Forth designed for use on elle(12-pitch) Titer.) Form Approved.OMB No.2050-0039 <br /> UNIFORM HAZARDOUS 1.Generator ID Number s 2.Page 1 of 3.Emergency Response Phone �/ 4.Manifest Tracking Number C. C <br /> WASTE MANIFEST 4�'S-vu1r,E; rlS4J 1 1—:%�;"Y,—:.i_,tj..1 ->•;!if # ^7t r•, .; • r�C - <br /> (3 3 r •r 193 <br /> S.Generator's Name and Mailing Address Generator's Stie Address if different than mailing address) - <br /> L;�1 yNCa <br /> CIA <br /> Generators Ph": 210S 021-..VS 1,Y' . <br /> 6' PAY Nams, _ U.S.EPA ID Number <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> B.Designated Facility Name and Site AddressAFF <br /> t_y Y U.S.EPPJD Number <br /> 17_"2 f- PER CREFs <br /> Faaltiys Platte: <br /> 9, 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers11.Total 12.Unit 13 Waste Cordes <br /> HM and Paddng Group(d arty)) No. Type Quantity V&Nd. <br /> — <br /> 0 <br /> z 2 <br /> W <br /> c7 <br /> 3. <br /> J <br /> 4. <br /> 14.Special Handling Instructions and Additional Information 5# I mar,ss; ,„s3 5242-4-507 w 2'yr•I1? _ <br /> G.a rIR K'1;ErcC, N Y 7 �r(Dt - 1 ttl3 i��Ftti�t—K �' ! - "4 13 E;: .. <br /> anU C,1'1t113s !N Itr,.� �,.is.4(g!: `.,l .tr,�ci I7!,.. .1 trx' i Ai r.AI . R'7 .r .,I'.2ru <br /> 15. GENERATOR'S/OFFEROWS CERTIFICATION: I hereby declare that the contents.of this consignment are fully and accurately described. <br /> bove by he pmper shipping name,and are classified,packaged <br /> marked and IabeleNplaarded,and are in all respects in proper condition for transport according to applicable international and national governmental regulations.If export shipment and I am the Pita x ' <br /> Exporter,I certify that the contents of this consignment conform to the terms of the attached EPA Acknowledgr.end of Consent - <p $�,'�, �- <br /> I ced fy that the waste minimtrabon statement identified in 40 CFR 262.27(a)(d I am a large quantity generator.bi(b)if I am a small quantity generator)is true. ,ry•• _t <br /> Generarots Pmted/Typed Name igna re a nt y <br /> p�^r!`ice <br /> —r 16.International Shipments <br /> - ❑Imparta U.S. ❑Export from U.S. Port of entry/exit <br /> Z <br /> Transporter signature for exports only): Dale leaving U.S.: <br /> w 17.TransporterAcknoMedgment at Receipt of Materials <br /> may, <br /> Transport 1 PiritedrTyped Name —---� f / Signature " ""2a"" on , ay., ear <br /> 13- � 7 ltel..' " U/ .l.e:. /�+ �F ^� { p i C. � Al <br /> Q Transporter 2 PdnLcVTyped Name signature.-— Month Day Year <br /> K <br /> F <br /> 18.Discrepancy <br /> 18a.Discrepancy lrldiation Space ❑ Quantity ❑Type ❑Residue ❑P.M.1 Rejection ❑Full Rejection <br /> Manifest Reference Number. <br /> 18b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> :3 <br /> Faci1' s Phone: - <br /> ywa 18c.Signature of Alternate Facility(or Generator) Month Day Year <br /> tR <br /> z <br /> y19.Hazardous Mate Report Management Method Codes(i.e.,codes for haardous waste treatment disposal,and recycling systems) - <br /> p1, 2. - 3. - 4. <br /> 20,Designated Facility Owner or Operator.Certification of receipt of hazardous materials covered by the manifest except as noted in gem 18a <br /> Printed/Typed Name Signature Month Day Year ! <br /> EPA Form 870D-22(Rev.3-05) Previous editions are obsolete. GENERATOR'S INITIAL COPY <br /> II � <br />