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Please print a to.(Form designed for use on elite(12-pitch)lypewdter-) Form Approved,OMB No.2050-0039 <br /> UNIFORM HAZARDOUS 1.Gonwsw ONumber 2.Page l of 3-Emarg my Response Phone 4.Manifest Tracking Number <br /> WASTE MANIFEST t2 ODa//&SSfo ¢ay 7 -Svr �f 0153$4271. JJK <br /> S Dareanofs Nom and Mining Address arena hSi'A Admess lA 6flamm plan=alike eddrevj <br /> 26r-rsrN�Ll4/2 14l/E- S fOCJ�7U/J 'C� `352(S <br /> Dnra:ispcdP;eno: 9 ''.Sn <br /> B.Tranbponarl Cunpany Nemo � ) U,S.EP��A/ylD himrlKr <br /> c <br /> YY 70N 4625�v( D 20-Z- <br /> 7, <br /> 7.Transposer 2 Company Name U.S.EPAID Ndwbsr <br /> 8Do�•nal ad Facility Name andSlleAddrass tU6Vo*QA /.any —ry U.S.EPA ID Number <br /> u.7 EC 1 606—9 or ���r7 , (�� e�1/r ��� 8'g003 <br /> tri q5', l[ d�tILES��jj))S- <br /> Farft aPhone: P6 — 3 s� �� ��v D� <br /> 9e. So.U.S.DOT Deudirtka(mduding ProperShlpping Name,Hazard Class,ID Number, 10.Containers tt.Talal 12.Unll 13.Waste Codes <br /> HM and Fading Group(it any)) No. Type Quantity VAAK <br /> 1, -3o-77, clSzwrW o 4^5 --�sT +o 01,111 <br /> ,o. R G o r Lg2o <br /> z� 2. --- -_ -- <br /> 1 <br /> 3. <br /> d. <br /> I <br /> 1 Spocla{HoMMg In6ltucMneand Addteonal ln&;rmallan <br /> Z0 ��! ^�np <br /> 1) �t CuGL 'r W J/J <br /> ✓¢�, [� OHO 5 -( 40 <br /> i . CENStATGR'WGFFERGR'SEERTIFICA7ION:Ihereby declare that the contents of iNs consignment am any and acormely dowilsed alem by the proper shipping name,arid are dawned,packaged, <br /> marked and lalmodlplecwded,and we In all respects M proper condition lir ma,po t according W applicable international and national governmental regulations.llexpod shipment and I am the Primary <br /> Exporter,I cenly that the contacts of this consignment onto=to the bents of the attached EPA Acknowledgment of Consent, <br /> I many,Thal the vreste minimhatlon statement Idenflned In 40 CFR 252.27(a)gl I am a large quantity generator)0(b)(III am a snail pb niiy generator)Is We, <br /> Gotwmlofsl0ffeI Pde00;1oN Noma SiOnaNro' MwN OaY Year <br /> G005P-T <br /> 18.Intomogoael Shipments <br /> ❑rnma U.S. ❑Expodiro=U.S. Podolerlrylexift <br /> Treneposar sigrdears,nor zfk"M poll Date loavlrg U.S.: -. <br /> 17.TranspoderAcknoWedgmenlof Receipt of Materials <br /> ZQ <br /> Transit" Y Sign <br /> TI Mm <br /> PMMonth <br /> r �DDay <br /> YYrea <br /> war <br /> enn yma ms tga <br /> e� e.•w <br /> RE <br /> 4. 18.Discrepancy <br /> Inc.Discrepancy Indication Spam n Charity ❑TYPO R..* ❑Pallial Reaction ❑Fdl Rejection <br /> MamissiRelatencoNferber. <br /> tdh,Allemato Facility(for:Goneneut) + n� rih'l)a.)_f:..z 7"}) U.S.EPA ID Number <br /> Z, a (J9ITCJcS^J^.f E <br /> LL Fadulya Phone: <br /> lea.Slgratae ofAllemate Facility(0,Ganoralolf In Day Year <br /> a <br /> z <br /> H19,Hazardous Waste Repos Management Method Codes(Le.,rock=for hazardous waste treatment,disposal,and recydkg stilette) <br /> 0 1 2. 3. 4. <br /> 20.Designated Fadfy Owner or Operall Certification of recepl of hazwdms materiels coated by the manifest as noted in Ilam Its <br /> Il PmtadR' me S re. Manlh DNy Year <br /> k -�. v\ <br /> EPA Form 8100-22(Rev,3-OS) Previous adi0uns am obsolala. DESIGNATED FACILITY TO DESTINATION STATE(IF REQ IREDj <br />