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Please,paint or typo. Frnmd"Opt9d form on elite(12-plkh)typewriter.) Form Ap ovaci No.20500039 <br /> UNIFORM HAZARDOUS I Gadwalm ID NrmOur 2.Pao td 3 Cncegle"cv Response pltn" 4.Manifest Tracking Number <br /> WASTE MANIFEST z ,5"5(� Z.r✓r; -st <br /> 015384256 JJ K <br /> 3,Gwmrabra Name andMalang MIII55 GeMgIpIF F&.Addut,to musurl e,ylmiaGnU aILaCS) <br /> EIS /ZEF/OJAI& c.. 6„ �2�� <br /> 2�2Z Ser �fr�cc. /,,L 'I� ATO 7l�� LA - �� <br /> 20`t 7 ,�3U <br /> GaNmtMa 19mne: - <br /> 6,TFWSN(ds 1 CNIpaly Hudd US.EPA IOyNN�UMmr y q <br /> G K-000/I§7 [ ZZ <br /> C Uz <br /> 7.Transporter 2 Company Nemo U.S,EPAID Number <br /> P <br /> m I.Desbgmled Fadliq Nargo era Silo Addlers I. EPA ID Number <br /> t75 &C 01- o c> y : v;9 0 P63 �9G�3 <br /> E� Tor/ <br /> A/EV404. v7 3300 0 <br /> Fadtil Phone: <br /> 98- 9b.U,S.DOT Desenpllon(Including Proper Slipping Name,Hazard Class,ID Number, 10,Containers 11,Total 12,Unll <br /> () 73.Waste Codes <br /> HM and Packing Group(If any)) No. Type Ouandty, W1JVal. <br /> o �� 317 r �figLg21xx�5 wYl57E I SUL.lD� I lg j <br /> 0,S Pb *9 a GF <br /> 2. vg s7r , St 10 l 5 <br /> 3m7 i d�7Z�2+7 ou5 �(�� <br /> I <br /> a <br /> I <br /> 14 Spedrd 14prace g I%w3hus,and AdddI Information <br /> s MIXeO c,. Lc,15r <br /> 15. GENERATOR'SIOFFEROR'B CERTIFICATION:I hereby dadpm that Rho canards W this consignment are(I and accuralely demlbed ahave by the proper shipping name,aid are dasslfed,packaged. <br /> marked and labeledlplacerded,and are In all respects M toaster condition for transport according to appllcade international and national governmental rogulalbns.U export shipment and I am nae Primary <br /> Exporter,I curtly that the contents at this consignment conform to the terms of the attached EPAAcknoaledgment of Corrsenl. <br /> I cerlN that the waste minimization statement Identified In 40 CFR 262.27(a)0f I am a large quantity pnf:wioq or(b)(II I am a small quardity 9enemt0)Is Ime. <br /> (-wYAnamrb'Olorw'g Ponledyf,�!Na Slpnatum _ -M1kxdl NY Yam <br /> tZtGai l C P,r--f%)I t > Oe <br /> J 1 .Imamall Shipments LJImportto U.S, ❑Dean loom U.S. Pon of WhYl-Al <br /> Trarmpoder sgnelure(ferexpods 0111W Dale leaft U.S.: <br /> K 17.Transporter Acknowledgment of Roselle 0 Materials <br /> 4anspnr '1 Prri e• 1Pmf Naw _ 4nMum �^k AMA9FrryIh 111 YearJ <br /> Tiepoder 2 PdmedRyleed Name 0 Slgnalue Mwdh Day fear <br /> r <br /> } 18.Discrepanry, <br /> 16e,Discrepancy Indication Spec. r1 Quantity ❑TYD to ,,���II���asry�u ❑ <br /> GPareal Rejectioionn ❑Full Re)nVan <br /> 3 m E <br /> bkuilclliulurerrc�•Wwnlr 1. <br /> 16b,Nlemalo Fedllly(or Ganmalor) !!d;.ii"AIU Number <br /> tMAII e 2 2011 <br /> U <br /> LL Fn�111Y:+Pawn' <br /> w I&Sli Slim of Nluraale Facility(or Gonerat;Q i-N NSu'. KIALF. AXTH Monte Day Year <br /> PEWITZERA✓E'3 4 <br /> H19.Hazardous Waste Report Management Method CodesOL&,codes for hazardous waste treatment,disposal,and recycling systems) <br /> coo 1_ 12. 3. 4. <br /> 20,Uus10oared I Ownerar C}maW.COnflution of receipt of hazardous materials revered by the manned exopl as Med In her,16a <br /> Poklk,YNIs New Serilar �n tDa�y <br /> I � V <br /> TEPA Form 870022(Rev.M5) Previous MiUuns are obsolete, 0@S1 C',I IAT 1iU I II ITY'I USES I If IAT 10N STATE(IF- REOIJI IEOj <br />