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Please print or type,(Form designed for use on elite 12-p(tch typewriter.) Form Approved.OMB No.2050.0039
<br /> UNIFORlyI HAZARDOUS 1.Generator ID Number 2.Page 1 of &Emergency Response Phone 4.Manifest hacking Number
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<br /> WASTE MANIFEST tpl 1.L.1J1.Y;r ..7si i''. . w .i:t 005
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<br /> 15.Generators Name and Melling Address Genera s Site Address(H ifferent than mailing address)
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<br /> Generato'sPhoru'
<br /> Trarsporter 1 company f+.
<br /> ..me U.S,EPA ID Number
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<br /> T.Transporter 2 Company Name U.S.EPA ID Number
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<br /> &D—*nated FName and Site as U.S.EPA ID Number f
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<br /> Fact s Phone: 2,10'. (i.5 - '),t;i
<br /> ga. 9b.U.S.DOT Descdp9on(Including Proper Shipping Name,Hazard Gass,ID Number, • 10.Containers 1t.Total 12.Unit 13.Waste Codes 1
<br /> HM and Packing Graig(darty)) No, Type Quantity Vilivol. f
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<br /> 14:Sp.edal HendliNq Instructions andAdditlona Information a ;; 7 f r'"' ,, !.b q.
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<br /> 15, G ftRAT.0.V.0*FFEROR'S CERTIFICATION:I hereby declare that the contents of this coosigrlrnent are fully and aawately described above by the proper suppling name,name,e'nd are classified,packaged,
<br /> mtgka'dr d fabeled"caided,and are in all respects in proper condition for transport according to applicable international and ne0onal,govemmentai regulations.if export shipment and I am the Primary
<br /> r I c8*that Ste contents of fids conslgrrrenl conform to the term:of the attached EPAAcknowledgment of Consent, • '
<br /> .;',beT6ly Uzi(he waste mfnimizedon statemed Identified In 40 CFR 262.27(s)(1f)am a large quantity genetator)or(b)(fl 1 ap,h sm3h,quanfity generator)is We.
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<br /> 16.fitsmgdonal Shipments " l
<br /> Olmport to U.S.' ❑Export frau U.S. Port of entry/elcf(;,.' f
<br /> Trans er s tura for ex only): Date leavin U.S.: i
<br /> 17.Tem iiportarAdufoWedgment of RecokADf Motorists
<br /> Transporter t Pdntedrrypod NameSignature r' �%? >.!' Year
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<br /> �.Transporlar2Printed/iypedName Allure g. Month ay Yew
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<br /> 18a.Dlscraparhcy fndkation Space ElQuaoily, ❑Type Residue ❑Partlel Rejection ❑Full M- action !
<br /> Manifest Reference Number:
<br /> 16b.Alternate Facility(or Gererelor) U.S.EPA ID Number
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<br /> W FacKlVs Phone:
<br /> 18a Signature of Altemate Facility(or Generator) Month Day. Year
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<br /> 19.Hazardous Waste Report Management Method Codes(i.e..codes for hazardous waste treatment,disposal,and recycling systems)
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<br /> 20.Designaled Faft Owner or Operator.Certification of recefpl of hazardous materials covered by 9x mantlest except as noted In Item 18a ;
<br /> PrM Typed Name —--" nature *�y-�-+.� v Month D ear•
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<br /> EP(rForrn 022(Rev,3-05) Previous e0.itionfe'ro obsofete. TRANSPORTER'.S COPY
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