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Form Approved.OMB No.2050.0039 <br /> Pleesa print or type.(Form designed for use on elite(12-pitch)typewriter•) 2 1 of 3 enrergency Response Pnace 4 Manifest Tracking number _ <br /> UNIFORM HAZARDOUS 1'Gener"lo Nmnbm ge 000037892 DP► <br /> WASTE MANIFEST -_x`10QQ,2k:6075 2 ,a, >; 5+7-2G_��t <br /> 5.Generates Name and Meiling Address Gear.Site Address(ddideren[gran mail'eg address) <br /> Iomh h g.: tEtfe 1 b <br /> 51 IiKl SOW R ;R;E <br /> - <br /> ,55+ c r rt 2r rT v <br /> Generators Phone h c".- t GR 'sL. '.:--�, :,"1 Is Tin "�# s�i5 fes::-:.148b 5� <br /> VL <br /> U.S EPA IDNumber <br /> 6.TmmPoner 1 Company Name _ <br /> L' tr =i'1R'' "•"^F Bt'i-35 (5'i'int!^e 18£li2 V? ..ns—�C7"1'123. <br /> US.EPAIO Number <br /> 7.Tansporter2 ComDanY wawa <br /> a.Desgnated Fadity Name and Site Address U.S.EPa IDMmiber ENVIRONMENTAL <br /> p ri e7 `;tlz:s HEALTH DEPARTMENT <br /> Fall' s Phone - <br /> d/ ..k (`.. .Culp_ ,r., >; `fE? r351 -�.`-":E - <br /> ye._ 96.U.S.BUT Description(mdadin9 Proper Shipping Name.Hazard Gass,m Number• to.Containers 77.Total 12.Urh 13.Waste Codes <br /> HPA and PadSg Cxo�(rfarry)) No. Type Uuanbry 6YUVol. <br /> ..�i tic:. <br /> O � <br /> Q � <br /> L <br /> t.. r <br /> 3 <br /> -------------------- <br /> i <br /> 14.Spedal Handing hadmalionsandAdd sonei Intonation <br /> 15. GENERATOR'SIOFFEROR'SCERTIFICA10N: 1he:ebay dsclara that the contents of this mnsignmem are fully W� dee <br /> =gxd atw.eMthe proper shipping nam,and are dass;fiE=..a_o__z_ <br /> madred and IaboadlPlamnled,and are in w respects in pmpar rendition for barra rt acmrffng to appirNe intT'r_ __ _radmW governmental legulatiene.It expos shipment and I am the Primary <br /> Exporter,I certify drat the wroems of this consignment comarm 0 the terms of the aftached EP.4Acknmdedgmer.:e C_'= <br /> I mrtty fiat the waste minmdzabon statement identified in 40 CFR 26227(a)(d l am a large quantity geremitsd or ` =-s"am generaft0e,hue.. <br /> Crene lots mrs T;ped P'atne Sig�¢i• ur2,�- I f ^ Madh Day Year <br /> �' G-: <br /> J iliAntemational5hfpments LJ hvw to U.S. ❑E.W from U.S. -_'-'anhylead: <br /> F <br /> 2 Transporter signature(for exports o*): ___sang U.S.: <br /> W 17.TransporterAcWwrAedgmentofRemo of Materials <br /> � ran <br /> Tsporter 1 adrryped Name Signatu.2 M0^� van <br /> v✓y„j / <br /> QTrammorter 2 Pdnledfryped More Si9n'al%;= ` Momdt C"; _= L <br /> q 16.9*aepancy - - <br /> 18a.Discrepancy Indication Space ❑ OuamAY ❑type ❑Residue -a_z--:_ : :—i Full Rejection <br /> Manifest Re`._ =_ <br /> r 1llb.Alternate Facility for Gereamlor) <br /> J_ <br /> V <br /> Facditys Phone. „ <br /> 93 tae.Signalure ofAllemate Facility JimGeneremr) Monts Day ._ <br /> Q � ! <br /> CD <br /> Z <br /> 19.Hamrdous N/aste Report Managemem MelMd Codes(l.e.,codes for hazardous raasrs:'ea:rer.._s:___-amd rezydag systems) <br /> 4. <br /> 711.Designated Fadlity Owner or Opei'etar.GedNcation of receo of hazardous materials msx„ §;the a+.andest except as noted in Item 182 <br /> Pmdedrryped Name --__. �•matne _ - <br /> � t <br /> EPA form 8700-22(Rev.3-05) Previous editions are obsolete. e- <br />