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Please print or type.(FoUn desgnod for use an wife(12-08ch)'typewritoc) Form Approved.OMB No,20560039 <br /> UNIFORM HAZARDOUS i.Gonaralm l0 Number 2Page 7 of 6ovrg c7 Respmsn Phwa 4:10an1los1 Tmcklne Number <br /> WASTE MANIFEST 015384272 JJK <br /> S.Drummers Nameand Ma1ro Addroscrmrat 'sme,Addml(d stressed man mating address) <br /> PCs <br /> Ganamfora Phwse . inlcGa9 /2 -v c�-r�)� chi_ <br /> 6,Transposer 1 Company Nemo US.EFA IO Number <br /> L <br /> 7.Tmnsposew 2 Company Name U.S.EPA 1D Number <br /> O,Coa lad I'mIriry Namo and Silo Addressr2�a� AID Nwhor <br /> 11Wg� �� rUrrr.�s S- �Fy, N VI <br /> FoculysPhwa: 3`1 . -3 - 33(v I o <br /> ga. go.U.S.DOT Description(Inali leg Proper Shipping Name,Hazard Class,ID Number, 10.CanlalnersH.Tolal 12.Unit 13.Waste Codes <br /> HM and Packing Group(Ilery)) No. Type Quantity WI.11101. <br /> x , � muA30-1z F ISI <br /> � <br /> 1 <br /> 2 2 <br /> w <br /> 3. <br /> I <br /> C <br /> 14.Special Harding lnstmclana 2Rd ddidOrml Information �d 4r'/1 L 017- <br /> � _ <br /> DwY60 cctiL � Y <br /> d . ;9-: 5qi - / 1 . �5760 I? <br /> 15. GENERATOWS(OFFEROR'S CERTIFICATION:Ihereby declare mad the contents of gds consignment are fully and accurately described above by the proper shipping name,and are classified,packaged, <br /> marked and labelediplacadad,and aro In all manacle In proper condi for Imnsportaccording to applicable Nlernafional and nallonal governmemal regulations.11 exparl shipment and I am the Primary <br /> Exposer,I redly that the contends of the consignment conform to the terms of the attached EPAAdmowledgmenl of Consent. <br /> 1 codify that IN waste mlNmizadion sdelemenl Idenrgod In 40 CFR 262.27(a)Is I am a hrgoquae6ly,flau r)or(b))d I am a small quantity gwleralw)Is Imo. <br /> Gemensfofsf011nals PrkrwdTyrAd NomaSlgmwro onN Day YaI <br /> G�9-Tb 0 t �Z o6, 1 DI I <br /> .-r Ir <br /> 16. vsmaeonal 5 ipmenls <br /> �. ❑Impel to U.S. Ll Export Iron U.S. Pon of enlrylexl[ <br /> Z Trensprror slgntdure(for axpass coly): Dale leaving U.S.; <br /> K 17.TrensporlerAckrwwtsdgment of Receipt all Motorists <br /> 0 fmns{sxlart PrvrlmlTyped No. N r c T �7 ,PIL11s � Sywluro M6 DoH Year <br /> Dan;y0rW 2 Pmrled. ypod Name cul (�f GgaMum Month Davy YoGm <br /> e- <br /> 16.Discrepancy I-� — <br /> 18d.DlwepaucylnslcalionSpam 13M� u DRowdue Partial Refar!bn Full Reectlon <br /> Vel <br /> IA.Gr u L-13-1v <br /> all <br /> 16b.Allemab Facility for Genmalar) U.S.EPA ID Number <br /> J_ <br /> U <br /> LL Facility's Phone'. K <br /> AY 02 2011 w iec Sigrakme afAlterate Fadtty(a Generator) Non Day Year <br /> w19.Hazardous Waste Report reanimated Method Codes(fe.,codes for hazardous wasteAmex slams) <br /> 3. - 4, <br /> 20,Designated Facility Dvmer w Operator:Gasification of receipt of hazardous materials covered by the mantles)except as noted to Item tea <br /> rimedfTyped WoolDay' ear <br /> it �J1 <br /> EPA Fo0n 8700.22(Rev.3.05) Previous edAOons are obsolete. DESIGNATED FACILITY TQ DESTINATION STATE(IF REQUIRED) <br />