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y. <Please print or type.(Form designed for use on elite 12 itch c <br /> -� ( P )typewriter.) <br /> t UNIFORM HAZARDOUS 1.Generator lD Number 'f <_ / s/ <br /> WASTE MANIFEST 2.Page 1 at 3.Emergency Response Phone Form Approved.OMR No.2050-C <br /> 5 Generetofs Name a I Manifest Trackin Number <br /> M Mailing Atldress oo�� $ r <br /> F d' Generators Site Atldresslif different than maili �4'� DAT <br /> B at ng address) <br /> ' r y k q '•. N?54 8':�&NN! n-iflaNtl, #4;. <br /> Generators P <br /> 6.Transpone,I and Nama :'i ...y•; •'�d� Ar S frjyy <br /> t:-'4 957'15 ;rviyA-_BY <br /> :p i U.S.EPAIDNumb¢r <br /> Z Transporlerl Co mpany Name �" <br /> r <br /> 8.Designated Fr A I'r ' r' U.S EPq ID Number <br /> 5 auliry Name and Site tldress <br /> p 1UG EPA IDN robe t <br /> : 7 .-ayaiRr N4 a.:S�i n <br /> WsPhone: <br /> 9a. 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class.ID Number, <br /> HM and Packing Group(if any)) <br /> s' t 10.Containers <br /> at 12 <br /> 0 'y1 No. TYPe Quanity WLNoL 13.Waste Cotler <br /> Jut <br /> 2. l✓j G;i!. tiYi i_ jr.5 iii <br /> 4 <br /> i <br /> 74.Special Handling Inslmctions andAdtlilional Information <br /> �5 NOV 102014 <br /> 15. GENERATOR'SIOFFEROR'S CERTIFICATION: I here } <br /> marked and labeled/placarded,and are in all res declare that Ih¢contents of Nis ibnsgnmant are Nlty _ <br /> Exponer•I certify That me wnlep ""in Proper conatppn for trans Intl accurately tleudbed�dve b me r <br /> is o/this coni omen( pori according to applicable international Ind nabonal bp}h y ¢pdr5hippinp name,and ar¢r;lasdiTM}• a <br /> I wNty plat the waste minim' d conform to the leans(the apach 90 menbil r ged, <br /> ¢aXon stale itlentifietl in 40 CF ed EPAAcknowladgment o(ConsenL glations.If exuon shi men) <br /> C7eneratoesl0)la rs Print R 262.27(a)(i(I am a larye guano ;` o and)am the Primary <br /> .�y F ed7TYp¢d Name 7 v ry generator)orb itl a - `3 f <br /> (1l a small quantitygenerator)is We. <br /> .�.. i r'f'' j/ / Sgnalure <br /> F 16.Inlemabonal Shipments / mac" ^�4://' p'L' .r' % " <br /> Month Day Year <br /> ? Trans ❑Impod to U$. ' ''r -" <br /> Poner signature(for exports only): Export from US. <br /> W 17.imnsponer AcknoMedgmenl of Receiptof Materials Pon o/ ,exit:._ <br /> OTmnspoder7 PnnteNT Daf¢kaving�}:$'—� ----- <br /> pM Na e ` ) <br /> Matson r2Pno IrypetlName x ' 'iC..1 s i � /�1; Month Da <br /> Signatud"----• <br /> t Y Year i <br /> y / �� I 1 <br /> 78.tliaeaperiCy •J%�` 'la-1 ,_ Month Day Year <br /> ,as Disrmpancy Indicator,Space <br /> u Quantity ❑ <br /> Type <br /> ❑Residue ❑Radial Re <br /> lattron ❑Full Rej¢clion <br /> 186.Altemale Facility for Generatpr) pp 77 <br /> -+ Manifest Reference Numbest��Of T <br /> U " <br /> a has the o�y�jf alsr l l <br /> LL FatilityS Phone: <br /> H18c.Signature ofAltemateFaality(mGenemb,,) for, and ill accep :taste ' <br /> 2 <br /> ad 19.Hazardous Waste Report Maria einem this genera o <br /> 0 1 9 Metltptl Cotler i <br /> 4..rCdCS fQ'ha------ Wdate 12atmBnt,di5 nth Day Year <br /> 2 Poral,and recycling systems) <br /> 20. es,gnated Faciliq Owner or Operator:Cena'amon of receipt o(hazar <br /> Pnnted/Typ¢d ryame tlousmatenal ,covered the mond <br /> by est except as ntl¢d in Item Iso <br /> r/ Signature T <br /> 'A Form 8700 11 <br /> -22 Rev 3- �'e v` /• Month Day near <br /> ( 05) Previous emlions are obsolete �'�' �'! Ler { <br /> 03-01 - 13A08 12DESIGNLi / 7 <br /> i� R C JC ATED FACILITY TG GENERATOR <br />