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'.late Of 005101`00–Haalih and Warfare AgencyDeDartmenl of H9rM Sol cIS <br /> Form Approved OMB No.2050-0079(&puss 9-70-91) ��/ See InsftcHons on ba0}. - Je 6. iaxic Substances Control Pegram <br /> Please print a type. Farm designed fa use on elite(11-pitch Npewnfer). Saacmenta.Cabl <br /> UNIFORM HAZARDOUS 1.Generalol lA EPA 10 No. Man$ea Documant No. 2.Pape l rdomxx on in he ahotlad area <br /> WASTE MANIFEST ^ "1 I 1 , I 1 of 'nOt ieaared by fedeid law. <br /> J.Genera la Name and MOWQ Accl A r^n A.State MaNi al Documed Number+ :.w JVt(� ^:. <br /> ' '.'�I. 4i f <br /> 2 .. B.Stare r»rafa'a <br /> A Gereratod Phone( ) – <br /> 5.Transporter 1 Comporry Name 6.IS EPA ID Number C.Sale Transporters b'.: <br /> _.� .. .. :D.'.TionripoRKaPhone <br /> 7.Trarvi 2 Compaq None S.US EPA ID Namber E Rate Jfarepottl to <br /> 1 I 1 1 I I I I I I 1 F.TdondoorteerPhone <br /> 9.Dnoaaleg E3q;Ny PNire anal Site 6dddial , 10.LIS EPA O Number G.State Facii ID <br /> I I ':t I I I fl t I t. f <br /> o 12.Contanea IJ_Told it Una <br /> 11.US DOT Deacrlptgn(nckciling Proper Shipping None.Hamra CI®.ane ID Number) No. I Tylpe 9uanfM v/hNol I Wrote NumDef <br /> a Rale <br /> Nc E b. state <br /> 0 <br /> 00� R EPAjOnff <br /> M(¢j A l 1 1 I 1 <br /> T C. state <br /> 3 R EPA/OlhrN <br /> o Rate <br /> m <br /> C <br /> N <br /> Q <br /> J.AtlWbfd Deaerptbnfu AbserCY Cbtea About KHarialingCodea forWmres t6tatl Above <br /> , "L�?t+?IC, b. <br /> c; <br /> Z <br /> w <br /> U I5.Special Haase+g Irshucllore aro AddTond Idortraikx, <br /> a <br /> N <br /> w <br /> c <br /> Q 16. GENERATORS CERTIFICATION: I hereby declare that the contends of the coreign ment are full anal accurately described all by proper shipping nae ao a,c= <br /> — <br /> z pocked.Modred.aro labeled,dna ale in of respects a proper mrorfan for harm by hphrcry aecordirsg to applicable kderrallond aro national govemrnerd regulations. <br /> C <br /> Qrf I am,a ape auadlN generator.1 cerlYy that I have pr %ne a a program n pace to reduce the volc!to dc*y of w e generated to the degree I how determined to be <br /> Z economicallyRaclkmis Real Mal 1 now relented the plocticable malof hW <br /> emerrt,storage.or disposal cueeMN available to me r ch mineral the Resent and future <br /> = that to humor health dna the ameor idixi OR.y I an a mal Qua l gererala.I hoe made a good farm effort to minimize my waft generation and select title beat Wade <br /> me nopemant method that is avalobb to me and that I can cdford <br /> QPrnfedrYped Nome _ SiQatun Mones Day year <br /> U <br /> y T 17.Traepoher 1 ACkno riedgement of Receipt of Materiae <br /> pR Pdnted/Typed Name slpnahure Month Day your <br /> A <br /> U N <br /> Z 5 <br /> w P <br /> C Q 1&Tornporter 2 Ackro ement of pecept of Materiae I <br /> R Phstea/TVpea Nana sprats* Monet Dory year <br /> w T <br /> E <br /> yS R <br /> Q F 19.Decrep rl Intonations SpoCe <br /> U A <br /> i C <br /> 1 <br /> L <br /> 1 20.Facility Owner or Operator Cer ificotion of receipt of h imardou mcfenoe covered by me manlelit except as noted in item 19. <br /> T Piated/Typea Ncme Sigril Monet Lay year <br /> Y <br /> I I I <br /> DO NOT WRITE BELOW THIS LINE. <br /> 016e1022A(12/90) <br /> Yellow: GENERATCR RETAIN <br /> EPA 1700-22 <br />