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Please print or type.(form designed for use onelite(12pi6 )typewriter. Form Approved OMS No,20560039 <br /> UNIFORM HAZARDOUS 1.0eneroax lD Nwnber 2,POP <br /> 'tof 3.Eaier9ency 4. �"y ! <br /> TWASTE MANIFEST C:.. , " ilirih i (077 . '5=7-2669 U. DAT <br /> . W s Name and Mating Address - Generetars SAM Review(lrainrent Nan me"Games) <br /> 19s116I9E til&£# .. Isis <br /> 11946 W fw{a 6yS ASlS <br /> 0enaatera Phone: OVER L48 W. Ns Ge M113WS21` iD6 t219)'id Y=!r::= <br /> 6.Transporter 1 Comparry Name S.EPA ID Number <br /> 21st Century Environmental. Manat)r sire 01 ;All. :ni.) . L i"41. .;,:1 7 <br /> 7.Tansporter nyName 1" I +.Y; a..;;. •. "'� U:B. PAID umber r.,. , <br /> 6.Dean,'.rawly Name am SAeAddrese U:S.EPA ID Number � y— <br /> RiW CIO Li C <br /> 42S Isis ANI., <br /> F sPtmne tk rtil. �. �. ,;- 71C-1111 <br /> Ba f =US De Icor'uamg Proper Supping Name,Hazard Gi ID NwDer. 1p.Gpd x s 11,Tm;-' 12.Uml <br /> HM �fiw",e`e Il No, Type CWMy 9AA*d 13.Waste Codes <br /> MICRO RM11011S 6951E all iV11i'UIMTWSIUR,� _) 117 332 <br /> o <br /> w 2. f91t RiIH1 114MOUS lolSiE Sat El IVol 13laMY;ilpl161C1 I <br /> a, WM 101v s0l.3 IFUI_ PEFFKp r'KSW 11 j 1 <br /> ° IRfYT39 1L fi.o.5. lS vii M 6 P611 11 3— <br /> 14. oal 1-himi ,ns are, may now <br /> seer Pg:n"•. kw <br /> 1kY W114-16 2€6b1 M 1 t21 TAci 1! 3s9-?16661"t1 - M A CH 16 -66 - 5 145211 RI i1) <br /> � � �SS <br /> 1 <br /> 15. GENERATOR'SOMRDRSCERTIFICATIDN: Irefecy.kvaima ft tllewmenbd Ups mnsignmoM are kch and moll the pmper shipping name,and are classified,packaged, & <br /> mda3aMd�ptaGadad.arwl wa.o as respxh in pm97m CpTtkBdn lw Umnpad accad"g b ap cabb miRA rcg,dxeoos.d export shipment and I am the Primary 1 <br /> Elmilor,loci old the contryd,ofme;roreYdmxNnl caloan 4 he berme dtha fPA of <br /> Iclaiiulna wale seasonalaembed n40 CPR 262.27(a)(el am awgequa" or(b)(il,Jarna +kwnarygeneatoi Is live, <br /> s yOedNmna Month _ <br /> 16.International Waparents ❑mporlto U.s. ❑Export ken U.S. .f PMolp0.ryleuc <br /> = TrwaW.signature((w evormlW4i. '•.. Dole"U.S.: —_ <br /> W Ti.Trans;edm ofReca'pt of Materials. /gp <br /> K T 1 Parma Mme, pa� Y r <br /> O � Elmo <br /> Trare" r2 Pmolaryold KIM Signature <br /> } 18.DisaeWcy <br /> 189.Disq parry lud ntim Space <br /> r, ❑ Dueraty ❑Type ❑Resrgpya�e'')` � � ..., n.. ❑Full Re)ecaan ; <br /> Mandest Reference Number, j <br /> .. € 18b.AAemeftrFa6My(or Can alor) . ._.._... . .. __. .__.. _.... _ _. _. . . U . AIDN r _.. .. . <br /> NOVf 201r <br /> rax. FadMya Phone: I <br /> gee.slgna —Aaamate Fadiry.(orcaneator) ENV!RON N-1 r:N!TA,I ,PEA-Ci Monet Day Year <br /> m_ 18.Ha7ardoue Wasm Report Management Medved Codes(i.e.,codes for hazardous waste treaonenl,disposal,and recycling systems) <br /> 01:1 I Hitt I 61,P Illil <br /> 1 20.Des7ated Faintly O.meror0pemtor ofreceipto(ha rdoesmatedalsomcredbyrhemankstex poet 3a <br /> Pnnted/Typed Name S Mo Da' Veor <br /> EPA Form 87M22(Rev.3-05) P vious edifi neo solei moi" DESIGNATED FACILITY TO GENERATOR <br />