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P rase faint or type.(f=orm designed for use on efiite(12-pitch)typewriter.) form Approved.OMB No.2050-0034 <br /> UNIFORM 14A7ARDOUS 1 Generator ID Number 2.Page i of 3.Emergency Response Phone 14,Manifest Tracking Number <br /> WASTE MANIFEST IUM,, . �¢ 0q3 jt 1a �` �� —� 005231779 JJ K <br /> 5 Generators Name and Mailing Address Generator's Site Addres (0 different than mailing address) <br /> if <br /> � 4, V � -S-q:313 <br /> Ganeralods Phone: <br /> 6.Transpolar 1 Company Name U.S,EPA 10 Number <br /> Epp f V 14 -0V tU 01I Ar+2 {1;aW!`3 <br /> 7.Transpo 2 Company Name U.S.EPA ID Number <br /> ti,Designated Facrlity Name and Site Address ttiO�MOLJIU.S.EPA ID Number <br /> Facility's Phone: <br /> ga, 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, itl Contaillws 11.Total 12.Unit <br /> and Packng Group(if any)) ldol. 13.Waste C>d0.5 <br /> No. Typo Quantity Wtl <br /> 1. <br /> HM - PIC101- m 7 �ry <br /> dO V�� <br /> d to <br /> a' <br /> z 2. <br /> W <br /> c� <br /> 3. <br /> 4. <br /> 4,SppciV Handling lnstruetiur�a a d AddiI naP Information <br /> a� <br /> 15. GENERATOR'SIOFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by the proper shipping name,and are classified,packaged, <br /> marked and Iabeledlplacarded,and are In ak respects In proper condition for Transport according to applicable International and nallonal governmental re90aGons.If export shlpmenl and I am the Primary <br /> Exporter,I Certify that the contents of this consignment conform to the lemrs of the aCtached EPAAclawwledgment of Consent. <br /> I certify that the waste minimization statement Identified in 40 CFR 262.27(a)(it I am a large quanWy generator)or(b)(ifLSWA.Nkall quare aretor)Is true. <br /> 64) 4orsf f nledffyped Na Signature M11Mh Year <br /> M �� !✓.4 / <br /> i 16.111afttlonal Shipments I__!II 11 <br /> import to U.S. LJ Export from U.S. Porilelexit <br /> Transporter signature(for exports only): DaleU.S.: <br /> 17.TrarmparterAcknowledgment of Receipt of Materials <br /> Transporter 1 Printed/Typed Name Signature Month Day Year <br /> feat G' iy I I <br /> d Tra sporter 2 Pnntedffyped Name afore Month Day Year <br /> ti <br /> 16.Discrepancy r yy <br /> 16a.Discrepancy Indication Space ❑ Quanllly ❑Type ❑Residue ❑Partial Refection L_1 Full Rejection <br /> Manifest Reference Number. <br /> 1Ilb.Wlemate Facility(or Generator) U.S.EPA ID Number <br /> C] <br /> LL Facility's Phone: <br /> 18c.Signature of Alternate Facility(or Generator) Month Day Year <br /> F-- <br /> Q <br /> Z <br /> 19.Hazardous Wasto Report Management Method Codes(i.e.,codas for hazardous waste treatment,disposal,and recycling systems} <br /> LLJ a 1J1 J / 2. 7-- <br /> . 4. <br /> k L//IJ <br /> 20.Designated Fa21 perator:Certification of receipt of hazardous materials covered by Ila manifest except as n In llom 1 <br /> PrinteVyped Nabe Signature M Ih Day Year <br /> EPA Form 8700-2 Previous edi ons are obsolete. DESIGNATED FACILITY TO DESTINATION STATE(IF REQUIRED) <br />