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Sep 04 09 03: 20p Lindsay Schwager 2099523389 p. 11 <br /> Form Approved,OMB No.2050-0039 <br /> Please print or type.(Form designed for use On elite(12-pdch)typewriter.) Z.Page—1.1 3.Emergency Response Phone 4.ManilestTmcbng Number, ^ F <br /> UNIFORM HAZARDOUS 1' resr .s Iy -*.F� !S :. -_4 <br /> WASTE MANIFEST "=-`-F A f 1 y`p"� ! ' Genemlars Sita Address(il dlRerentthan mailing address) <br /> 5.Generator's Name and Mail'mg Address <br /> r Ta7")1 <br /> Genmatoes Phone: - U.S.�p A D.Nu�pbad� <br /> t167��x!.(1(ea"fd'1!T 7R�:M <br /> B Trenspl"CN <br /> •. CID <br /> •"'-. U.S.EPA ID Number <br /> . <br /> 7.Transporter 2 Company Name <br /> U.S.EPAID Number�y�a <br /> 8.Designated Fadtily Name and SiteAddress s r a.J V?J IL {:)•� 't <br /> D- <br /> {� r.7uSIS@. �A{! fiat"'.'.� tia.`•t:.:_✓a.:--:'_= <br /> Facililys Phone: lo.Containem 11.TOIa1 12.Unit 13.Wasi Cadee <br /> ya gb.U.S.DOT Oescrip8on(including Proper Ship Name.Ha am Class,ID Number, No Type Ouantity wtjvd. <br /> HM and Packing Group(If 010 j <br /> W ' <br /> 4J <br /> 4. <br /> 14 Special Harddng lnsM1ucdora andAddNoral lnformaWn - <br /> '.,J,.. i f1T1{a.. 7 `--cn�-,. 'tf !. : .. <br /> 4 <br /> ;ame,and are <br /> PIS <br /> y and a ra <br /> 15. marked al abelleNPE carded and eel inAa lON: I hereby declare that d-respe=in pour condfi�for transport accpmng to applicables ounsignmesh are ilnternational andynatioa governmental mgroa�rre.�IPfa�orl sM1Mment and lamf the Pn packaged, <br /> Exporter,I codify that the moments of this consignment conform to the terns of the adached EPA Acknowledgment of Consent. <br /> I certify that the wade minimization statement identified in 40 CFR 262.27(a)011 am a large quant- 9eneratpr)—M(rfl am a smatl quantity generator)rs orae. Monty Day Year <br /> S ng aN� <br /> GeneraloY9O8erofs PdntWffyped Name <br /> i . i, x ht 1 <br /> 16.In1em95onal Shipments ❑Export M1rm LLS. Pott leaving U.S.:i- ❑Import b U.S. Date leaving U.S. <br /> Ensporper <br /> sporler sign ure(for exports anty): <br /> Wransco Ackrawledgment m Reoelptof Male 'a <br /> t Month Day Year <br /> r 1 Prim�Yme ;� r gnalurei _ Month Day Yearrt PdntedlTypad Name - 9nature -- <br /> cd <br /> } <br /> 18.DiWepancy <br /> I tea.discrepancy Indiratbn Space ❑ Quantity ❑Type ❑Residue ❑Partial Rejection Full Boat i. <br /> Mandesl Reference Number: <br /> U.S.Mail Number <br /> 1 go.Alternate Facilely(or Generator) <br /> J <br /> V <br /> ua. FaWllys Phone: Manlh Day Veer <br /> W l oc.Signature of Alternate Facility(or Gene Ston <br /> a <br /> sal,antl r s terns <br /> m 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous weals treatment.,tlapo 'InYc1 n9 Ys 1 4 <br /> W 1 2 3. <br /> 0 <br /> 20.Designated Facility Uvner Of Operator Certification of rece pt of hazartlous matetials covered by the manifest except as nixed in Item 18a Monm Day Year <br /> lprimeGTypeo Name <br /> EPA Form 870082(Rev.305) Previous editions are obsolete. <br /> DESIGNATED FACILITY TO GENERATOR STATE;IF REQUIRED) <br />