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Pt r hrne �rcnin <br />•3,. � � n X1'1 11 y�^1 <br />e on elite 12 -pitch) typewriter.) - WYE 14 9 L.,F � Form Approved. OMB -No. 2050*3b <br />FEB 1 2 2015 <br />ay.. Bar <br />i <br />DESIGNATED 'FA ILITYTO GENERATOR <br />UNIFORM HAZARDOUS : 1. Gene tar ID Number [jM ' <br />WASTE CX U�.60009" ." <br />2. Page 1 of <br />S. Emergency Response Phone 4. Manifest Tracking Number <br />' <br />MANIFEST <br />% <br />008745312 JJK <br />editions are obsolete , <br />5Generetaes Nam,and MaFng Add 1/p - Ganem ssitpyddress (Ifdidifferent than mailing address) <br />��rfdaLAO <br />., ,. AHrC arnle �a,avSM5�. <br />�p 9:90 �qe ✓t' • 32Yi [.o•c . r a <br />Gdrria T -Irk KS 6Gal/ s+�e tl c 95aus <br />Genemlo'es Phone. %� f ' <br />9l ' 3e�} <br />6. Transporter I Company Name U.S. EPA ID Number <br />h W1roilfw �Hc IRooat?3G�°:i <br />7 Tmnspgrler 2 Company Name � \ �,•�- U.S. EPA ID Number n' <br />1 , <br />1'\bl fV1] C F C11i1 1 CCIrOOVZ�:��� <br />B. Designs- Facdity Name and Address ! C`k1^I tAr �., rG�NjM en A6 A6r7�emeh cC ('✓Al Y4yjjiS.FPAIDNumber <br />FacllitysPtione: 7r5- 5. - 2 Gu N✓D9�Ofi 95 338 <br />ge. <br />' 9b:U.5 DOTDescdpflon (Including Proper $hipping Name, Heard Class. ID Number, <br />10. Containers <br />11, Total <br />12. Unit <br />13 Waste Codes , <br />No; <br />Type <br />HM <br />and Padding Group V any)) <br />Quantity <br />Wt.Nol. <br />1. v ! as C' �'.'lfvlt Hln a5 FS a �.5. nvhe'f <br />s) 3; ('(,f <br />'331 <br />s�ISI <br />GZ) <br />pr'j <br />.!G'-4- <br />Dcr�1 <br />z <br />2. <br />r; <br />3. <br />4. <br />14. Spedal Handling Insbec0ons and Addlflonal Information YI c Yc hYC , 'r ;. , -' 0 / <br />l <br />4 E4ea-5 P� <br />15. GENERATOR'SIOFFEROR'S,CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by, the proper shipping name, and are classified, packaged, <br />. marked and labeled/placarded, and are N all respells in: proper gonditlon for transport according (a applicable International and national governmental regulations, ff export shipment and l am the Primary <br />Exporter, I oemty that the contents of this consignment confgmi to the terms of the attached EPAAskngwledgmentof Consent <br />I certify that the waste minbmzaton statement Identified In CFR 262,27(a)(ff l am a large quantity generates) or( I p a small quendty generator) is due. <br />Gene toe ori PrintedRyped Name Sig neNre Month pay Yew <br />F <br />to. International Shipments " i - - - <br />❑Import to U.S.' ,❑Export from U.S. '� - Pon ofe I <br />Transporter signature (far exports only); Date leaving U.S.: <br />w <br />17. Transporter Acknowledgment of Receipt of Materials <br />K <br />Transporter s Pdmedfryped Name Signature : - Month Day Year . <br />a <br />1 A Tofu Ce 4 Gv/olrfy Q &51 <br />QTrans <br />ode 2PnnteJR ed Name Si rialg\� Mo�n]m p y. Year^ <br />18 Discrepancy-:- <br />jjj7, �y( <br />iBa Discrepancy lndsahon Space ❑ `?4t CE'M of N T ❑Residue . al ReJ � r �❑Full Rejection <br />has the - c <br />a pprapriate permit Manifest Reference Number. <br />l8b.Ahemete Fecllity(orGerawator) this. -0.S. m <br />Tile waste I�PA"i i 2U' -..i <br />9ene►ntor <br />_ <br />is shipping. <br />u <br />Facility's Phone: <br />'W <br />18c. Signature ofAltemadwFadlitg(or Generates) -.,. ,' �• .-_.. •':. ..� -... •�_'-'".'. "' th :- Day . :..Year .. <br />. HF "r 11010"4rT' <br />H19. <br />Hazardous Waste Report Management Method Codes (I e. irides for hazardous waste treatment, disposal, and recycling systems ) '"• <br />O{ <br />1' <br />2 3. <br />4, w.. . <br />-� <br />20 Designated Facility neror Operator Cerbflca0on of receipt of hazardous materials covered by the manliest except as Wed in Item 18a. <br />Pnmed/fyped Name r ignm r <br />y�. <br />FEB 1 2 2015 <br />ay.. Bar <br />i <br />DESIGNATED 'FA ILITYTO GENERATOR <br />EPA Form 870022 (Rev. <br />3-0) Previous <br />editions are obsolete , <br />FEB 1 2 2015 <br />ay.. Bar <br />i <br />DESIGNATED 'FA ILITYTO GENERATOR <br />