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- Porro Fpprover OMB No.2040-0039 <br /> Please print or type.(Form designed for use on elite(12•pitch typewriter.) 2 PaOe 1 of 3 Emer9enuy Response Phone .Man 1 Tracxiny Number ��� <br /> 1.Gmamtpr 117 Number ppryry <br /> UNIFORM HAZARDOUS t „ t.F#„' <br /> WASTE MANIFESTt <br /> 5.Genemtets Name am Mailing Address Ganerabra Site AdtlrBs6ii dgerentihan morning address) <br /> P�s <br /> CsBA I°t4r.T'v! t t •�� <br /> (� <br /> , 0 952i7Y; <br /> Genemices Phone: '- - U.S.EPA ID Number <br /> 6,Transporet 1 Company Name <br /> �r^, <br /> 7.Transm 12 Company Name <br /> LLS.EPA ID Win., <br /> 8,Designated Facility Name and Sita Address <br /> Facie s Phone: 10.Containers 11,Total 12.Unit <br /> Gp A 13.`Neste Codes <br /> 9e. `�"U.S.WT pascdpliah including Prope:Shi n Normo,Hazard Class ID NUT6ac No, Type Quantity Wlo'Vol. <br /> and Packing Group(n any)) <br /> r <br /> a <br /> z 2. <br /> w <br /> a. <br /> 4. <br /> 14,Spedai Handiny Inzavcurens and Additional Infor abort <br /> eby <br /> PPIng <br /> nd am <br /> d. <br /> 15. GENETmarkeATOR'and TOFF ROWS a RTare inallm proper condition 6rmstp uirt,oisacccon ding90 app6cabie ilntematyand araIatnd national ggov�rrantaltreguleons l tl export element aM i amaihhe Primary Wanted. <br /> Exporter,t certify mat the conlents of this consignment conform to the term of the ansched EPAAcknovdedgrnent of Consent. <br /> I candy that the waste minimizabon statement alerid0ed in 40 CFR 262.27(x)(if I am a urge quantitygenembri or(b)If I am a small quantity generator)is true. Month Day Yew <br /> Signeaire <br /> Genemtoes+Oterols Prnledayped Name <br /> ..l ifi L2 Inielnnal SNn rents <br /> import to U.S. '�I Export born U.S. Pod of entrylexiC _......____.Date leaving U S.: <br /> Transporter signature(`ar experts only): <br /> W17 TransWrer Aoknorxledgmenl of Receipt of Materials Math Day Year <br /> p Transporter 1 Fdntad'ryceg.NITe Signature ,.�'";•> /'f <br /> S r !r�A�. Montn "Day Yew <br /> QTronsportor2Printod(TYPad Nam, Signaf <br /> 18,Discrepancy rf-''TT <br /> 18a.Disaepancy IndicationSpaceElquantry <br /> Type LJ Residue tJ Pamal Rejection ._Fail Reioetion <br /> !8' Mantlest Reference Number <br /> U5.EPA ID Number <br /> tBb.Nlemate Facitty(ter Genaretor) <br /> J <br /> V <br /> W Facility's Phone: Idonth Day Year <br /> w 1 .SiAnature of Ntemab Faciity(or Generawr) <br /> 6 <br /> z <br /> y19.Hazardous Waste Report Management Alethad Codes(ia.,cordae for hazardous waste beatmenh disp3sai,and recycling systems 4 <br /> 2. <br /> 20.Designaled Facility Owner or Operator:Certification of receipt of hazardous materials commd by the mammal excopt as rated n Item 183 pn'h Day ear <br /> sips awry <br /> Prinluctzyped ame <br /> EPA Form 8700 22 <br /> DESIGNATED FACILITY TO GENERATOR <br /> (Ret-3-051 Previous editions are obsolete. <br />