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Please print or„ .(IForm dash ned for ose on elite(12-p1t181 ( awnlei) Form roved.OMB No.2050-OD39 <br /> UNIFORM HAZARDOUS 1.Gawmisr IDNum6w - 2.Page tel xEnur Response Phnue 4.MaNfeel Tracking Number <br /> WASTE MANIFEST --3- 015384195 JJK <br /> 5}Cwppraw"s Name Ind Nal Addaas MrOb/s SiNAdBless(d ddorenNnan mNemj eddrnss) <br /> 6.Transporter 1 Company Homo us-EPA ID Numbpr <br /> sG Ajew- char � � zz <br /> D Number <br /> 7.Tmpwled2 CAmpony Ramo U,S.EPAI <br /> o <br /> 6.DeslgnalollToday Nome and Site AddressJl.--� �aJ U.S.EPAIDNumber <br /> u5 Eccac'nG.� NElii�rJ� � 'i"'``- <br /> Fx!Nys Phone: 'A •.. � �- <br /> ge 9b,uS.DOTOesaripllonlinduding Proper Shipping Name,Hazard Class,M Number. 10.Containers 11.To1a1 12.Unit 13.Weals Codes <br /> HM and Pockin9Grcuppfany)) No, Typo 0 Ary NANd. <br /> o <br /> 30-7-71 tigz14tZ rS v�gsTE� apt <br /> U o l <br /> 3. <br /> 4. <br /> %Spadollizod lnsln,cfwlts emlAddlWnfil mAxmalbn /O C-4 Y4411W 5 4Y4411W5 <br /> 15. GEIIERATOIRSIOFFEROR'S CERTIFICATION:I hereby dedaremal,Ir-conlenls of this mndgnmentam fully and accunday doscurodabove by the proper stopping name,and are classified,pacNagad, <br /> marked and IabeloNplaarded,and Ile In all remade In proper condition rortrmwpon aaording to evpli(ada International and national governmental regulations.If export shipment and I am Ne Primary <br /> Exporter,I sedify that the conlern s,of this consignment sonform to the lerms of the ruched EPAAcknowledgmenl of Consent. <br /> -I cetlly that the waste minimlzallan slatememldengfled ip 40CFR26221(a)(if lame:TargequaeUlygerennot) r a <br /> ,esmall quwl9ry generelor)IaINe. Month Da Year <br /> Grmefaloi s/0ITI Pdnlad/lypW Name Signal y <br /> J I6.InIedwOMd BI,P^a'Is ❑Impotlm U.B. ❑Expodlrem U.S. Pon of entrylaNll <br /> Dale Inavlag US:: <br /> Tmnspodur0A,mbue(IN 94101 - <br /> W 17,Transpoderkknodedgmenl of Receipt of Materials <br /> TranspkNr l Pdnlw9fy . Noma SgnaN Month Day 7 <br /> ���I �'a � fcFyN 9 /G <br /> Transputer 2 Ppnla�YTypad Nmne Sgneture Month Dq/ Year <br /> 18,Discrepancy II�-II <br /> 18a.Discrepancy lndlcallen Spaca C] cwrery DTypesidu ,T,y LJPamal Rejection ❑Full Rejacdon <br /> REQ; t fL <br /> 186.Internale Fadaly(a GanWela) <br /> MAY <br /> {�y U.B.EPAIDNunda <br /> v MAY7 Q :� 2Ua/ <br /> n FadNWs Phone: <br /> A] <br /> w 18c,Sq'P;kmrformite Fbonty yal CVMI110r) Mohllt Day Year <br /> a ��(vt�orlm��rs,L fIG^a-Tt, <br /> GO 19.Hazardous W0510 Report Management Method Codes(Le.,codes for hazardous waste VeeMen, ,a 11t-- ',syr ems <br /> Ul 1. Z 3. i. <br /> 20.Deslgnaled Facility Owner orOperaloc Congestion of racatplof hazardous materials covered by the widest nxcapl as nod in Item 188 <br /> SiBnmvm Month Year <br /> P nledR59edN , <br /> EPA Form 8700-22(Rev.3A) revious Pedi' sareobsolete. DESIG ATED FACILrrYTO DESTINATION STATE(IF REOUIRED) <br />