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Please print or type.(Form designed for use on elite <br /> (12-Pitch)typewriter. <br /> UNIFORM HAZA <br /> RDOUS 1.Generator lD Number <br /> WASTE MANIFEST Gs*.c, r'sr- „� -2:Page 1 of 3.Emergency Response Phone Form Approved.01 <br /> 5.Generators Name and Mailing Address t 4'M�tifgtitoiJ4d,pB u �^ <br /> a?t$>xP°ROUIg3 i u;,d;p,{-p--g Generator's Sflegddress(if ddterent than mailing aodress) <br /> yTCfd:75'Y>rrAl, <br /> Generators Phone:::if3....,.a+Cln i <br /> 6.Transporter 1 Company Name - <br /> tZF•4ft:xS Et.1':RRCrh;1,9E*TfrAL„:L6t nci: ;;+ <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> B.Designated Fatality Name and Site Address U.S.EPA ID Number <br /> SISOUFlfa' <br /> -tCY1 FA@Th ra ix:1UlL.FvAf4t31EY U.S.EPA IDNumber . <br /> Sit.a.O:PJCL�S.E' ,C.+§ ;e3 <br /> Faglitys phone: idN3�.#�.T3�.i Cr'cCT:k',r'�; <br /> 9a. -91).U.S DOT Descripryon(ncluding Proper Shipping Name, <br /> HM and Packing Group litany)) p7 9 tab Class,ID Number, <br /> 10.Containers <br /> nGm L;#+ILiRt_.I,gti kTF.ALI 11 10 <br /> No. 11.Total 12.Unit <br /> ' U€357 Ype Ouanti 13.Waste <br /> S#,fJiGCl77,E%ts w'OLtT7 FdC1s, Cyt T ty WUVcI. <br /> LU <br /> t8 t ?.CkA"rS) <br /> f } <br /> W 2. 'f�[a F irx� x <br /> 3. <br /> 4, <br /> 14.Special Handling Instructions andAddihbnal Information <br /> FdH,fj F�fiCuElt�y,F <br /> E.F COh,'if,gr eRGM71 <br /> HA14D P'AArlClw E:ttitgy{et €la-ay?'s'v. , „ v oo! <br /> LER"xHt71.-'1.d3 lyf' tTe ki€tiH'LY . Pal?617_-"Ae - <br /> F'CeC3' 9 F'F'F <br /> 75 GENERATOR'SlOFFERORed Dn'I—TIF—ICA—TION-1 am herebydpercondi the confents'ofthrs conslgnmentarp4ully and accurately described above by Nepropershl m name arq are classified, ac <br /> mah andlabefe at the conte anare m all respects m properconditi n for transport accbNm fo a livable International and rias al overnmental re regulations If <br /> Exporter,I certify that the contents of this consignment contarm to the t ruts of the attached Jnq to applicable <br /> of Consent, FP g <br /> I certdy Nat the waste mimmizeVon statemeent idantiOed 1140 CFR 262 7(a)(it I e a a large uantl g g amort shipment and I am the Pdr <br /> Generators/OflerorsPnnfgd4yped Name <br /> g 9 III of(b) am a smalluantl <br /> t, generator)IS We <br /> Signal 1%, <br /> 9 A' . <br /> 16.International Shipments a" '^" " ' f <br /> '' ' i •, M'`„ ] Month pal <br /> ❑Import to U.S. <br /> a Tmnsportersignatum(forexp,,t only): <br /> ❑Export from U.S Port ofentry/exil <br /> O17.irdnspodergdmowlcygment of Receipt of Melanie, <br /> Transported PnntedRyped Name Date leaving U.S.: <br /> a � Signature 'C <br /> Transporter2 Pnnted/Typed Namedrix:"1c< `'e S r> .. <br /> .4 'i v- y -Month Day <br /> 1" Signature <br /> TT18.Discrepancy Month Day <br /> .� 18a.Discrepancy Indication Space <br /> ❑Quantity I—�. <br /> ALJ Type ❑Residue <br /> EIParfiai Rejection ❑Full Reja <br /> 18h.Altemafe Facillly(orGenemtor) <br /> -� Manifest Reference Number. <br /> V <br /> Facility's Phone:' U.S.EPA ID Number _ - <br /> 1, 18c.Signature ofBltemate Facility(or Generator) <br /> a <br /> z <br /> m19..Hazardous Waste Report Management Method Codas(i.e.,codes for hazardous wasMonty" .Day <br /> 1. tmem;dfspoeaIIand recycling systems) - - <br /> T. te trey <br /> 3, <br /> �- 20.Designated Fadli <br /> Pnnfed? ty0vn <br /> !er or Operator.Certification of receipt of hazardous materials covered by Ne man'rfest except as noted In Item 18a <br /> yped Name <br /> Signature <br /> EPA Form 87OD-22(Rev.3-05) Previous editions are obsolete. Mont Day <br /> mill, GENERATOR'S INITIAL I <br />