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Please prUal or Type..(Fumr desig_nod for use on elite(12.plil lypbwrilef,) Form Approved.OMB No.20500039 <br /> UNIFORM HAZARDOUS 1.Vent➢ler 10 Nurber 2.Pinel al Emerg Rospansa Phony 4,M4mmmet Tmeking Number <br /> WASTE MANIFEST )��r�Lx�r✓.::=_1 IoS,Sb oa ���_'5 015384257 JJK <br /> 5.Gmremluru N.une and NaImgAUdrass erwrolix s Kmr r"Ik g oddo sa) <br /> CZ s 12 GC I A-)t <br /> � r71/E S roG,tcTo}il � , q �2.I <br /> Genu3w%Phak: <br /> G.Twitt.porltr 1 Cmi:panyl7ame U.S.EPA ID Number <br /> /4AI9 SON L-A/r/l_. 00�C� 1-727-L <br /> 7.Transporter 2 Company Name U.S.EPA ID Number _ <br /> B.OesIHrwLed Facility Norm and Slli•��sL✓S C'� r� U.S.EPA ID Number�J" <br /> tfwl� els , Ir arc ;. or I>E;lTry 0 <br /> FaclktPs Phony: 2�C'( "7 7 3 T 300 0000 <br /> ga, 91h.US.DOT Descdp9on(including Proper Shipping Nam,Hazed Gass,ID Number, 10.Conlalners ii.Toial 12.Unit <br /> HM and Packing Group Of any)) No. Type Ouandy W1 No. 13.Waste Cedes <br /> o X Nft 30-7� , <br /> PG- 2-Q 649 � <br /> z 2. <br /> I i <br /> 3 <br /> 4. <br /> 5d SUefial Ha"nrlyMsm'lrl-n�slna4nns ani Ml<Illlrvial lnrmmmMon /42 ` 1/Z•_.S p(' <br /> 1)I c [fes l <br /> I xs <br /> Sf/ �37�5 <br /> 15. GENERATOR'SIOFFEROR'S CERTIFICATION:I hereby declare that the contenis olthisconslijrumerA areluly and accurately described above by The proper shipping ruene,ard are classified,packaged, <br /> marked and labeled/placarded,and are In 81 respects in proper condition for Transport according to applicable Inlarnallonsland nmtlonal govammental regulations,If oxport shlp81en1 and I am Are Primary <br /> Expodea I caddy tha the contents of this consignment conform To the terms of 0m attached EPAAcknowledgmenl of Consent, <br /> I certify that the waste minlmlzalion slatemanikentifred In 40 CFR 262.27(a)If I am a largo quantity generator)or(n)Of am a small quantity generator)N Imo. <br /> Goneratoes101(o6i's Ptnled7Fyped Name SI9naNre /� --• Month Day You <br /> (L.I o�t�TO vl 09 l <br /> F 16. nlemational S6lpmerts ❑Expwlto.U.S. Port ofenl lent: <br /> F- 11 import to D.S. 7 <br /> Transpoelersignature(foraxporls,Mill Date leaving US.: <br /> ac 17.TranspoterAdvawTadgment of Receipt of Mmedals <br /> Transpormn I f7lubt,49 Nerne ' h4tm0r nay vesv <br /> H '- sN � F CONK rti .t, u —. r <br /> Tr:ntsp,vinr 2 P;411 Tyr"Nana. Slgntiaro IMvdh Day Year <br /> A le.Discrepancy <br /> 18a Discrepancy lndcalkn Space r_ Quantity Type n�� ❑Paeat Re)cgon <br /> FUI Rgecdon <br /> MonlfaelRefamnce Number. <br /> 18b.Alternate Faclliy(or Generator) U .I E011 U.S.EPAIDNumber <br /> J U <br /> u <br /> a <br /> LL <br /> Facility's Phone: [u <br /> w 16o Signaliseow-male Felty for Gsnaalor) i� (I IT-., Month Day Year <br /> z <br /> 19.Hazardous Waste Repel Management Method Codes Tim.,codes Ter hazardous waste Treatment.disposal,and recycling systems) <br /> o i. 2. 7. 74- <br /> 20.DesgAlod Fealty Owner or Operator:CeNncation of racelplof hazardous materials covered by the manifest except as Wed In Item 198 <br /> Prbtnd'lyl- I /' Slgmavo Mbah Day car <br /> V' <br /> EPA Form 8700-22(Rev.3-05).Previous editions are ntePado. DES IGMATED FACILITY TO Or ST(NATIUfd STATE.(IF PEni.li it, l?1 <br />