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Please print or type.{Form designed for use on elife^{12-pitch)typewriter.) Form Approved.OMB No.2050.0039 <br /> UNIFORM HAZARDOUS 1.Generator Id Number 2.Page t of 3.Emergency Response Phone 4.Manifest Trerldngr�N (� r <br /> WASTE MANIFEST V iJ:i1U , 'd5" 1 t w"'-':;="d O 0 3 61 31 O 7' �JJ K- <br /> 5.Generator's Name and MalllgAddr@ss Generatods Site Mdress(t ditferentthan mating address) <br /> �t` ���'t��'�r��', �'.:t1,:''lli�r.-''p Erl:.::lf�s: �• yii �" <br /> 12 <br /> -r� r.i�,:�i �� ..� icit!R :�C'v;t`:34 III•. :`�o <br /> Ganaratot's Phone. <br /> $.Transporter 1 Company Name U.S.EPA 10 Number <br /> 7.Transporter Company Mame a, - U.S.EPA ID Number <br /> S.Designated Facility Name and SlteAddress U.S.EPA ID Number <br /> INC, <br /> —'t�� YMME f i rib- <br /> - <br /> Pacirii}+sPhoho; �:��:•=:�:t,4-.:.°. <br /> ga. 9b.U.S.DOT Descrpfiw(hduding ProperShlpping Name,Hazard pass,ID Number, 10.Containers 11.Total 12.Unit 13.Waste Codes <br /> HM and Pecking Grasp(if arty}) No. Type QTY WWc1. <br /> � 1• ic?ii':-�t'F:.�;��+�.:��+u��:�ti:c;. T �t«i�W l;fSSf:. L=ts!'<h .. ._�. <br /> to <br /> LU <br /> 1 <br /> 3. <br /> 4. <br /> ' r <br /> 14.Special HamtlI g Instructions and Additional Information <br /> ;.ir.;f; - ^ �1= ,;:� G1�'�. Mr'G tF' 20te ERG'aZ 17t <br /> ., . . <br /> 15. GENERAMR'SIOFFEROR'S CERTIFICATION:I hereby declare that the contents of this oonsigrvnent are talky and 2=umtaty described above by the proper shipping name,and are dasstfled,packaged, <br /> ina(ted and labetedrplacarded,and are hi st respells In proper conddlon for transport sm dlog to applic>3ble International and natanal govemmentat regulatlau.If export shipment and I am the Primary <br /> Exporter,I certify that the contents of this consigrm rit mnfbrm to the terms of the attached EPAAc moadedgmank of Consent <br /> I'pertfy that the waste miniruzatim statementidentfied In 40 CFR 2=7(a)(tit am a Wp quantity genemtor)..w(b)(fl am a small quantity generaWl is true. <br /> esK&rces Print,&Typa N gnaw r1 rv"0 f If�� Month Day Year <br /> fr <br /> F CS�Inwlnafi6aal S'iprwts `� r <br /> ❑Import to US. ❑13pmt om U.S. Port of entryladt <br /> Z Transporter signature{tor exports only): Date leaving U.S.: <br /> LU 17.TransporterAdmoWedgmont of Receipt of Mateetals _ <br /> Transporter 1 Prtrded[Typed Name e--) SgnartuTe �+ Month Day Year <br /> JJIT <br /> 4 Transporter 2 Prtntedlfyped Nara Signature Month Day Yedr <br /> tr <br /> t- <br /> 18.Discrapar ay tI----�I <br /> 10a.Diserepaeeg Inclination Spam Ella entity ❑Type ❑Residue LJ Perdal Re)ection ❑Fut Rejection <br /> Manflest Ro%mr ow Number. <br /> 18b.Akernate Fadlfty(Dr Generator) U.S.EPA ID Number <br /> U <br /> r4i FacTO Phone: <br /> 1tic.Sgnatira of Alternate Fatality(or Generator) Month Day Year <br /> 19.Hazardods Wasta4 pod Management Method Codes(.e.,codas for haaardatswaste treatmeA disposal,and reuing systems) <br /> 2. 3. 4. <br /> t <br /> J, <br /> t/r <br /> 20.D@OjhatedF*iltyi3Ovmer orfSperator:Certif natton of recelptdf hazardous materlals covered by the meni 0 as noted In Item <br /> Pynnt9tllfypad Norma' -f , l � ). '�• � Srgrtature f -••,� �• Y� a '� r <br /> EPA Form87-0{ 22(Rev.305) PrevibuiattitiortssreMete. !f rl n f' DESIGNATED FACILITYTO G ERATOR <br />