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... .. <br /> Please print er type.(Form dean ed for use on elite(12-pitch)typewriter.) Forrn Apgoved.OMB No.2050-O39 <br /> UNIFORM HAZARDOUS i.Generemt ID Num6ar 2 Page 1 of 3.f:mengeuy Rmponss Phor:e 4.Manges!Irawk g Nmnber <br /> WASTE MANIFEST G s /- 1 S3°'6-6�- ZB YI 000239754 GBF <br /> S G—ramrs Name end Magmg Address Cenwalora She Address in owerent gen mehmg address) <br /> Ti-�c y N� L` S�Lf <br /> Cermrewsptc - <br /> 6.Tnumpoder 1�C/m,npany Nam U.S.EPA 0 Number <br /> A— :[ ovlJ. C <br /> 7. puler 2 Company Name U.S.EPA Di <br /> 6.DeSWAW Fadfi y Nene and She Address <br /> Ee— X- <br /> US.EPA I <br /> �.is Qw...- 13 JJ J. I?;-f 1, o-. L/ �.4 . er Y-9q 1 <br /> F ePMre SY - C <br /> 9a. �.U.s.DOTOeeMptlm(uldWhg� PPin9 Name;Huard CMss,ro Number. <br /> M end Paddng Gmup(day)f 10.Containers 11.Toly <br /> Nn Type Ouantly <br /> -aa <br /> S cS t S>zo 4 ov1 lcoa <br /> 2. <br /> 3. <br /> 14.Spada)RaMfng .and Addition ushrmeun <br /> �4./ �-dr.E 1'r G <br /> 15. GENERATOR'SIOFFERORS CERTIFICATION:I hereby declare mm Ne wm et$of M w wFaftemare Adel and awurnely desc iesd above ay the proper bNpphg rartm,artl area dassebd,PadAf;eq <br /> mblmd enc labekNpladNed,and are m A respells N proper wnfton fartrensparl WwdN to applkable intemabandand national goverwrental regulators.g aput eNpnuy and I mit the Pomary <br /> Eaponae l Ca"Net Ne wmmila of N.k mmignmommn/arn b die tarmm of tlm n adeed EPAAdvmknjgmdm of Consent <br /> GTercromdhmNan*Wil—osmkmerd dangled 1440 CFR257.27(81(g I was longe 4uenatygenomtor)or(D)(hl am a snwl qumdhy gwwramrla mm. <br /> PmbNTypeh Nartm <br /> JV S711. Sgmuue 'Hugh Oey rear <br /> t <br /> 16.b�brn8tbnd SNpmmtN <br /> i ❑ImpMmU.S. ❑'rxpon awn U. . Pad mentry�ehn: <br /> Trussed regremre(laezpats usy}. <br /> Dam leaving U.S.: <br /> 17.Tmneputy AdmoAlednxml d Readt nl Metugls <br /> yped N,a^m <br /> ya Q Yh�g H yYv- 'e"-P,Z Sgmhire Mardi Day Ya—m <br /> G Tmn�oihr2 <br /> novamm <br /> S �.3 1.QY• 0i <br /> 1 <br /> MmWe D91' Year <br /> i15.Dkueparay <br /> iu-Uegrepamy kdGaom Spam ❑ 0aarghy ❑7m, ❑Residue ❑P.W R"chm ❑FWReIed" <br /> 16b,Nlarmb FadYry(u Cenvaiorj Monika)Referenm Number <br /> ..a US.EPAID NumOer <br /> v <br /> LL Fapidyb PhgM: <br /> 18c SiplatusdAhamale FadgY lorGmaeatw) Month Day new <br /> 2 <br /> q19,Naimdous Yyaale Repot Manapemmrt Hatred Codes!ie..COON fm henicte b waste lreemreet disposal,and <br /> OW 1 2 recyrdng sSGlamsJ <br /> ( 3 4 <br /> 1 <br /> 20 De gna ed Feauly roma Cperetu Ceddmb of ramgollazmdas rtum ms me e;b he nor ma em ra are aging in lbm 169 <br /> Y�ad Name <br /> Slgnelure Muth pay Year <br /> Lox <br /> EPA Form 6700-22(Rev.M5) Prev d ealsosa,sogsolele. O3 4 <br /> ESIGNATED FACIUTY TO DESTINATION STATE(IF REQUIRED). <br />