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Please plard or type. Form deal for use on eUte(12-pitch)lypewrlter.) 7JI&W7S PPW D1/1Gr200f�' Form Approved.OMB No.2050.0039 <br /> UNIFORM HAZARDOUS 1 Gene I Number 2.Page 1 d 3.Emergency Response Phone 4.M nits t Track' Number <br /> WASTE MANIFEef."�: t_ ; �:o;o s�� .e.� .:a.;�: :.. teo�.r e ,v 1 3 8638 F L E <br /> 'S. eneralof9 Add .—_ Generator's SSW Address(H ditWeN than"ming address) <br /> Gencratws ' <br /> 6. <br /> (fin lnparryNirne U.S.EPA ID Numb <br /> 7'�4 .=LTi <br /> 7.Transputer 2 Company Name U.S.EPA D Wmber <br /> B. (r U.S.EPA ID Number <br /> rr.r +'•r� ,.s.�us +r ` i6�tri+y:z •�,.r:.y 2 1 7 7 <br /> •�,.r. <br /> Faciivs Pherte <br /> q0. 9b.U.S OOYDesllipiar gU,c +rg Proper Shgpig Name,Hazard Class,ID Numbe(, 10.Con 11.Total 12.Urn( 13 Waste Codes <br /> HM and Packing Grmp(11 any)) Nb. Type Quantity WLW. 1 <br /> w#1� J �. .►•. :4... N.. l .. Nor\^^/ t..0 .. .r.t..-�`. A 511,•K'�'..e{!t`' � :.{�41 <br /> Xp311 <br /> W 2 <br /> c� <br /> I <br /> 1 <br /> 4 <br /> I <br /> 14.Special Handing rnslnrSons and Addillonal Informarion 1 CH29M7B ER00171 <br /> 15 OENERATOR'SIOFFEROR'S CERTIFICATION: I hereby declare that he owlents of tKs ccnsgmrrt are fully and accuratey described above by the proper shipping name,and are Uassi:red,packaged. <br /> marked and labelodlparxded,wW are in all respects in proper condition for transport aaa6ng to appiCaDle inlemational and national goverrsnentai fe9thsibm If export shipment and I am to Primary <br /> Exporter,I cerWy rat 11*contents of this oonsigment conform to the terms of the attached EPAAckrmw"rnent of Consert. <br /> I ceriffy;hat Ilse waste mimai4alion statament identified in 40 CFR 262.27(a)of I am a large cusnRy gererabr)or(a)fie I am a anal Quant ty generator)is true. <br /> GeneraWS/Offerofs Prinledlyyped Name on 02Y Year- <br /> Jo �, , Wv, L O'a <br /> ri 16.Imerna:ional Shipments <br /> F— Import to U.S. ❑Export from Port oI entrylexiL <br /> ? <br /> Transporter swaturs fa Data leawbg U S.: <br /> w 17.T Adonorredgn ant d Receipt of Materials <br /> ,ansporter PrhlWyped Name Signalve Month Cay. Year <br /> y RvG <br /> 2 Transporter 2Prrnedfyypea Name n1r Dar <br /> a <br /> z <br /> 18.Dfsraepancy <br /> 18a.Discrepancy fnefcation Spaca ❑ Quantity ❑Type ❑Residue ❑Partial Re(eclion ❑Fri Rection <br /> Alanfest Reference Number <br /> 18b.Alterra'S Family(or Genera" U.S.EPA 10 Nwmbe( <br /> 1 <br /> U <br /> u- FaiditYs Phone: <br /> W 18c.Signabre of Alternate Facilly(or Generator) MMh Day Year <br /> a <br /> z <br /> N19.Hazardous Waste Report management Method Codes 5.e.,codes for hazardous waste Ifeaknent.disposal,ant rcuyciing systems) <br /> c 1. 2 3, 4. <br /> 20.DeAnated Facdty Owner or Cgeralur.Cedif eEm of receipt of hazardous materials covered by Ra manAust except as noted in Rem 18a <br /> PrintWyped Name 59'wv a Monde Oay Year <br /> EPA Fofm 6700.22(Rey.3-05)Pre*us editions are obsdete. DESIGNATED FACILITY TO DESTINATION STATE(IF REQUIRED) <br /> Caen Haftm naa tM approo tle pannus lfw and ova agape to waaa to ganataW-js.M Wra. <br />