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Form A(aprcved OMB No.2050-0039 <br /> Please print or type.(Form designed for use on elite(12-pitch)typewdter.) 2 pan 1 of 3 Emergency Response Phone 4.Manifest Tracking Number <br /> UNIFORM HAZARDOUS 1.Gncerator in Number <br /> V9 ; <br /> L"GS <br /> WASTE MANIFEST I _ - 4 <br /> S.Generator's Name and Mailing Address Generators NIS.Address(gdilferent Nen mailing address) <br /> f t,c, ;r.j <br /> $ IAR!iR LANE <br /> Generators Phone <br /> U S.EPA ID h'umtt!f <br /> E Transporter 1 Company Nimet <br /> US EPAIONumber <br /> 7.T•anspertor 2 Company Nam. <br /> f , <br /> U 5.EPA ID Numhcr <br /> 8,Designated Facility Name and Site AddreSS <br /> Facint'a Phone „ <br /> on.U.S,nor DescnpGon(dmduding Groper S^:o'ng Nanre.Hazard Class.ID Number, 10.Conroinars 1'_Tarot 12 Unit 13.Waste Codes <br /> HM and Packing Group is day) No Type Duangly WLNd. <br /> QO <br /> K <br /> Z <br /> W <br /> ID <br /> 3. <br /> C <br /> 14.$pecia..HanSing Instrucllums and Additional!nlarmaian - - <br /> 'S. GENERATOR'SIOFFEROR'S CERTIFICATIONr <br /> : I heeby nonan that the contents of Nis cuog;. e;. Ora fully and accurately described above by the proper shiVPng tome.and ere desai8ed.Uadmged, <br /> marked and IobeleNp oWdod,and am in dl rionads in proper condition for pension according w applicable international and national goin modenlel regulations.It export shipment and I am the Primary <br /> Exporter,I certify prat the contends o1 this consignment conform to the renes d the atzsched EEPAAcknott edgmem of Consent. <br /> I cefbfy that the yrasio minim¢ation statement identified in 40 CFR 282.27(a)(if I am a large guaMdy generated)of(b)if I am a small aided'ty ge .rata)�s We. M1IonN Day Year <br /> GaOefabl'SflOBarors PjrinladfiypeJ Name 9lgnetu .-_- X <br /> J 18.Intemadanai Shipments ❑mportm U.S. ❑Exponfrown U.S. ^Port of entryiedt: .___."..... ._. ----_._. - <br /> F Date leaving U.S.: <br /> '�— <br /> Transporter signature(for actions onlYY <br /> w t7.Treraparer ArAmtulndgmem of ROONIA of Materials - Monty Day Year <br /> transimner 1 Parted(Typed Name Sgnature <br /> 2 Monty ay <br /> IJ <br /> Tra sperter 2 Priv edf"yped Name Gignatxre — <br /> DYee <br /> i8.Discrepancy I <br /> '.8a.Discrepancy IMicanon Space ❑ Ouanllty t-1 Type ❑Readies Partial Rejector ❑Full Rejection <br /> ManBest Reference Numbec <br /> U.S.EPA ID Number <br /> 18b.Ad ermate Fadkty for Generator) <br /> J <br /> u <br /> LL Facility's Phone: Monty ay Year <br /> W 1. c.Signature o tomato Facility(or Generator) <br /> Q <br /> z <br /> w 19.Hazardous Waste RePw Management Method Cotles(i.e.,codes br hazardrne wash treatment,disposal,and racydinq systems) <br /> 3 4. <br /> 20 Designated Facii Owner or OpeMor-GeNfce6on of tie H,'haxxrNoua maledels uoveredbyfhe me2. <br /> ndrix exreptn,nctedln horn l8n Mont ay ear <br /> Ih <br /> EPAF `870 2'L(Rev.3-05) Previousedifions are obsolete. DESIGNATED FACILITY TO GENERATOR <br />