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Please pltnt or type.(Form designed for use on elite(12-pitch)typewriter.) Form Approved.OMB No.2050-0039 <br /> UNIFORM HAZARDOUS 1.Gentrator ID Number / 2.Page 1 of 3.Emergency Response Phone 4_Manffest Tracking Number <br /> WASTE MANIFEST ( ,.Ae ����{;���� nZ1)90—s64 1005231780 JJK <br /> 5 Gan3.::Vs Name nevi MaKng Adirem Generatrrs,11!e Address(A d'dfereM than mailing address) <br /> L <br /> Gelr5nt t3A Y,Wz Sy.313 <br /> Generator's Phone: <br /> 6.Transporter 1 C Jrrfpany Name U.S.EPA ID Number <br /> MOAAQ 6QV!QP NwgA c, I CATO kGo INZ-13 <br /> 7.Transpurter 2 Company Nance U.S.EPA ID Number <br /> vf2 X51 <br /> 8.Dewgrtated Favi Nan a and Ste A�d,�C-11Q vC V.S.FPA IO Number <br /> 111010 Vj ilTh st- <br /> 6(3 <br /> Fadbys Phone: B Ovf— &-Ze+ 6,'Z""1 I e-AO Q?—,bT oqj o f'1 <br /> ga. W U.S.DOT Descripticn(ir—d thing Proper Stepping Name,Hazard Claw,10 NwIAM, 10,Coritaire;rs 11.Total 12.Unit <br /> jiM and Packing Group(d any)) No, Type Quantity wt.rvdt. i3.'Neste Codes <br /> C,3 1N1 1200 <br /> 352 <br /> 4. <br /> 14. <br /> Sp-ml Handing IrStrwdiors a ,ddd ararl tbmal <br /> bG'!�T�OQ Dq779q <br /> Me 5,0 1-4 <br /> 15. GENMTORWOFFEROR'S Cf:RTIFICATtON: I hereby declare that thJ cmtents of this consignmeot are hdy and mately described abmm by the proper shipping name,and are classilted,packaged, <br /> nruked wid and are in all respects in proper ooridWun far trarupofl a.-=zkr*!o applicable international and national guvemm ental r uW—ions.If ezpurt slllDmenl and-&F M Primary <br /> Exporter,I ce"brat the coMeril s of this consignment conform to the iem7s of the attached EPAAcknDwWgmen[of Co;awn!. -- <br /> 00Wy lfiat the woste ndnirni?aWn statement identified in 46 CFR 2622749;(if I am a large qucntlty generator)or(ot k"sma9 quantity gonoratorj is true. - <br /> GeneraW ods Printodfrlped Name Signsh Year <br /> 16.Ir4ematrunnal Shipm?rtts <br /> Irttpert to U.S. El Export from U.S. Pafl of oalryfoxit: <br /> — Transporter sirnatare jfcr exports only): Date leaving U.S.: <br /> Ix 17.Ttrans x rlei-A knawLadgment of Re=zipl of Materials <br /> r—CLTranspotter 1 Pn&-dfTyped Nano: So^nature "ff,-7—(2— - <br /> Month Day Year <br /> a yy 1 <br /> T spwter Priramc Sij;T4 IT Mun:h Day Year <br /> 18.D4aaparxy _ <br /> 18a.Disaepaicy Indication Spacegg � <br /> puanL'iy ❑Tyte �R=sidua LJ Portia!Rejection �~ ❑Foil REjeCon <br /> Marilest Referertee Number. <br /> 18D,Attemate FacAfty(or Generaarr) U.S.EPA ID Number <br /> t.? <br /> iter FaNirfs Phene. <br /> Wnature 18c SigofAltemab Faduly(or Genaralor) Wrth Dav Year <br /> Q <br /> Z <br /> 6 19.Haaardous WazlI,,K,pwt Manage,nent MOW Codes(i.e.,codes for h.az a-d rus waste troatmersl,&,-.oeat,and recycling systrans) <br /> LU 1. ) 2, 3. 4 <br /> 20.Ded%maled Fa xn pr!satu.C+-sltrir akll of tai:eipt Of hr MMOUS rmtariala orivred by Itw manaest except as noted in Iters 189 <br /> Pnnkxaypcd Name vr� Signature th Year <br /> EPA Farm 87 - ev. -0`°) Previous editiDns are obsolete. DESIGNATED FACILITY TO DESTINATION STATE(IF REQUIRED) <br />