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12054366 Published by J-J.KELLEH 6 ASSOCIATES,INC�,Neenah,WI-USA-(800)327-6B6B•www pkeller corn-Printed in the United Slates 167-BLS-C 6 10495 <br /> Please Ilitl or t po (Farm des{grlvd for use an ekle t2 pitch)lypeyttrl¢r.) Form Alrtrrlr:crt OMB No 2050-0039 <br /> UNIFORM HAZARDOUS 1-QM01yr 10 Ndmbar 2.Ppb 1 rrf 3.Emhf gb vy Response Phone atkln Numbar <br /> WASTE MANIFEST (,q r cal a�� � 7 / e.-y#�_toe:, �J�9��7 7 5 J JK <br /> 5 Gertamwx Rame and 1rf:rl N AJdrdss rt N✓rfl o N i 9r;✓�A; J��<r��; w x Sle AdNess(d warm 91411 m5krig addn-s5) <br /> q s�qGK <br /> 45.0.?- Comr7;r'ta OO6R -,--V LcC l Sema �- <br /> .70113 /l/19Yi .i9,1-I e' �Or N;3✓`� l3ie/✓et <br /> Sz-,>e 1W :ani L'4 es15-w2ol6 i on/ , C'44�o2o6' <br /> flant<afols Phone: .c - Ytncy <br /> fi,,rim veer r ramyeny Harm U.S.EPABp Number <br /> SES c Y✓rf'd ti�l�l: i 5.fi,!/�rr J <br /> r Trnns x}nrr 2 Ceroprnty Nama <br /> US£PATO Nesnbo+ <br /> 6 fh•tign fort 6aGtily NemB and RIIOAd fie56 U.S.EPA IO Number <br /> CRO S,lf'7f ti" p ci�h''i O:� /ry/[•' <br /> %fox' L[J, .7 1J <br /> f:L•L's Photla: S�(c:e- 4/.3�- -,I 614,ia <br /> 9a. %U.S.DOTDesp*lon(including proper Shipping Name,Hazard Class,ID Number, 18 Contalnera <br /> HM aral Padung G-P IU-Y)) 11 Total 12.Unit <br /> 1 No. Type Quantity WLN01. 13.Waste Codes <br /> 3ae <br /> x 2 <br /> L1 <br /> I <br /> 3 <br /> Fr� <br /> 14.Svet:4lfmfdilnp 1MMKBWrs and AddlOU Inform;IWA <br /> I) I10T.3'! <br /> /J,tc l c« OV.a r R E:. S: I!?�N W Po/ ✓0,5 Vii' '76 a I -i <br /> d.•�fs2 AP��a�A-r.A 7'e? �F'rc .:Jlr,t ;�fJA-CG,rJ a 611 f Cs S 04 u..r.'s E.S' c o1 I ti <br /> !S![..c. %O +Q.�I�,C, c,e}� rw/i�(t?.['47 L� 4�✓IC�.xJ <br /> 15. GRFERATOR•8lOFFEROWS CEFMFICATFDRr I hereby dadve that the contents of this consignment are fully and accurately dawitted above by the propershlpping name,and are dassified,packaged, <br /> marked and(abeledlplararded,and era in at,respects In proper condition for transport according to applicable intemafional and natllrwl gbrernmrniv regulabons.11 axportshipment and I am the Primary <br /> Exporter.)certify that the contents of this consignment conform to the lemrs of the attached EPAAcknowiedgment of Ca hseM: <br /> I rwirify that the waste minimization statement idenfified m do CFR M.21(a)(illi am a large gtkmhly ganeraldr)crib)(dlliAra sma �vrpty ganeratar)1s We. <br /> GerlMasxs1011r,o!,rr;n fyp„d N Si(JnaSoro tionlh Aty Yrnr <br /> ,J lunt rllydnaiShlprnnnla r{-l� <br /> Z L_1lmport to U.S. ❑Fatpolt from U.S. UPad of entry/exit: <br /> Transputer srgnehara Iforetports only): Date kavirlg U.5.: -- <br /> W <br /> 17.Transporlrr AcFnowledgmentof Receipt of MafoAais <br /> irarlSporter 1 Pentedrlypedflnrre S�gnaty ?Terdh Day Year <br /> IL .I_- ,, -L, ITAY `2.ti_ l Z ZC A6.TranspaFn 2 Pr<nt y{1ed NamS nn MWO Day Year <br /> 16.Discrepancy <br /> 18e.Discrepancy Indication Space <br /> ❑ Quantity ❑Type ❑Residue ❑Partial Rejecfion nR.jeWn <br /> +tiro Wtahnale Faoty(or CeI4m) Alamfr�l Rularence ku nhcr <br /> _ U S.f:PA ID Numtwr <br /> J <br /> V <br /> rai F adiiy s Phone: <br /> 5lgnahua of Ahanwtn Facitity(or GanotaWr) Month Day Year <br /> Z <br /> H19,Hazardous Waste Report Management Method Carlos(I.u.,codas for hazardous waste treatment,disposal,and recyCu+g systems) <br /> W <br /> 1 2. F3 __ <br /> O <br /> 4. <br /> 28.Desiiirwird Facibty Owner or Operator.Certification of recetpl 01 Hazardous materials covered by the menifesl except as noted in Item 18a <br /> rMIM+IYped NAMP —nntuu. hSonIII DAY Year <br />