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01/21/2010 12:25 2099834012 FRENCH CAMP PAGE 02/05 <br /> • • <br /> Please print or type.(Form deb' fled for use on elite(12•pillch)Wessma.) Form Approved.OMB No.205D-0039 <br /> UNIFORM HAZARDOUS 1.Genera INumber 2.Page 1 of 3.Errlagenq Reaparee Finale 4.Manifest Tacking Numb" <br /> Ge <br /> WASTE MANIFEST '+� !' w,_ + w' ^ri 4 r-HU+v-^4n 1-' ,3',R��' 00334 .1789 <br /> �7�, 6N 7 JJK <br /> i.Generators Name and MetipAddress i „; OeamaW5SitgAckVPB(If dll e m Than onal atlal <br /> Cartel Phorre: <br /> 5.112nepp(ar„1YC�gtu_y. tl�lq C.nidi 1 xmidF[�(Ij sw,,{bg� U.S.EPA`DNum6rRr <br /> C� fit! CjA6,PA224 ''328x:' <br /> 7.Trerepprter 2 Canpeny Name U.S.EPA D Number <br /> 9.Designated Fall iiiiiiiiii SlleAddress wwfQf0Gn "I"SC, U.S.EPA ID Number <br /> it eWS3 WihAfrl. <br /> Facd'esPh": 5104or-4400 <br /> 9a. 96.U.S.DOT DINWIdion(ndudkq Proper Shipping Namq Hazard Claes,ID Numbw, 10.Coll em 11.Total 12.Unit <br /> HM and Packing Group(farry)) 1Vd. 13.Yyaele Codes <br /> C.. .M. Nom m <br /> 1ppe Qua <br /> t r .. e <br /> i <br /> z 2 <br /> W <br /> of <br /> t0 <br /> 3. <br /> 4. <br /> 16.Spedal Handing lnstmctions and Addlitonsi lnfomretion <br /> 15. GENERATOR'SIOFFEROR'S CERTIFICATION: I hereby del tW mP conhints of this consignment are IJIy end acaaacdy described above by this Prow shipping name,and are dassaod,postal <br /> marked and lebeled/platarcod,and are in all respects in proper condition for banspod aComdin9 to appllcaNe intemetionel end national goveo mental regulations,If export shipment and I am the Phrrery <br /> Exporter.I certify that the onntygs of this consignment cadmn to aW terms of the aaacheo EPAAcknuMed9ment of Conamt. <br /> I ceoy that the mele oltni nilatlon statement identified In 40 CFR 28227(s)(d 1 am a large QuenliH generator)or(b)(ifI am a small Quell thermal is true. <br /> Generabfa/08emfaPdmedRypad NameI Signature .. ,___.._....-. Day Year <br /> J <br /> A. Shipments <br /> ❑ImpMbUS. ❑Expert from U.S. Part of /edh- <br /> Transporter still(for epons olthy): Dale letal U.S.: <br /> 17.Transporter Acknowlecounind of Recalipt of Milanese <br /> Trara7rt 1,fin yped Name Signature tdonlhDWI. vssr. <br /> n <br /> Tensporter 2 PMteolyp¢d Name Sere <br /> Marts Day—Year <br /> r <br /> A. 18.Discrepancy �I <br /> 18a.Disaepency Indication Space El ❑Type ❑Residue L..IPenlal ReleCon ❑Full Refection <br /> or Gaaretor Manifest Rererenw Number <br /> 18b.Alternate Fadli <br /> H( ) U.S.EPA ID Number <br /> J <br /> V <br /> rat Fal Phone: <br /> 18c,Signature ofAltemele Fai for General Month Oay Year <br /> a <br /> z <br /> 19.HszaMWs Waste Report Menegarent Method COON(i.e..code*for hazardous wasie ttreatment disposal,end molioll System) <br /> 1. 2. 3. <br /> 20.DNignaNd FsdkH Omwa Operamr Cerfifcahm of re O olha7&d maknials mvemd by da meniW except as Med In Item lea <br /> Pr hollyped Name Signature Month Day Year <br /> EPAFoIm8700-22(Re¢3-05) Previous editions are obsolete. GENERATOR'S INITIAL COPY <br />