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.� Fans A proved,0 M No.2050-0039 <br /> :ase. rint or typ®; Form designed for use on Fite(12- Itch)ty ewritbr.r q,M ntfa t Trac rn urs <br /> 1.Generator ID Number 2.Page 1 x>< 3. mergency Response Phone q 4 X17 24' JJ K <br /> UNIFORM HAZARDOUS !� ,�, <br /> WASTE MANIFEST r, n c; 7 ai <br /> Generitofs site dress(if dRarant lhen mailing address) <br /> 5,pgner5tprs Name and Mailing Address <br /> '!lilt 1.'c� ltd>>r'v59 <br /> ��}33S t,ft -4.741 Generaidt'9t'Prtona: U.S.EPA ID Nu er <br /> 6:TraPsporter Company Name + ps <br /> 7.Tra ny Name <br /> U.S.EPA ID Number <br /> B,Deaignaled Faclft Name and Site Address <br /> C.l_�:J�Eiift:NfY::ft 'c'��V(!�l:+�I'�1•I•i*;k. <br /> 7A'it1 Al.A"WO 1111sllf= <br /> NV la°zs�1�4i e: <br /> 40111 {rets 1(I^'fi,il�4i. 10,Containers 11,Total 1x.Unit 13,wqWCodes <br /> w r Shipping Name,Hazard class,ID Number, <br /> Aa. 9b,U.S.DOT D sc ptiaft rricfu utg rope No. Type Quantity, WLNd. <br /> HM and Packing Group(d any)) <br /> AV h� 1 N :, 1t 5"4'..i{Olflt;(r;�ii.r�WAl'L'.b!.j <br /> 2. 1 <br /> ( r. <br /> � <br /> 14,S�� Hand r s• n•, <br /> I' <br /> 1 4 =k{P>~•.' lista <br /> re <br /> ified,packaged, <br /> the proper <br /> lig <br /> 15, GENE RATOR'S fGPFEROR'S CERTIFICATION: I t ersby d er gand'RI n for transportaccordng to apP.ble Hbonall and nabondf 9 remme ytzf rz9�aOn3''f�rt eNpmsnt ndalam the Primary <br /> marked and labeledlpiacarded,and are in all raspscss in prop _ <br /> Exporter,I certify that the contents of this consignment contorm to the terms of the attached EPAAcknowlee rear b C f I a m`small anerator)is VA. <br /> — <br /> Exporter, <br /> artily that the wash he 00 tet on statement identMed in 40 CFR 262.27(a)(if I am a large quart*g ) ( ( � '� qu i ± 4 Day ear <br /> ! Sign�4rre `i j �y <br /> Generator'el0>terors Prntedliyped <br /> 6.Inlern on ipmeri s Import to U.S. ❑Exporl from U.5. Port of entrylaxit: <br /> Data leaving U.S: <br /> z Transporter signature(tor exports only) <br /> 17.Transporter Ad nONIOdgment of Receipt of Materials Signa re Ma th Day Year <br /> Transporters ted(lypedName <br /> Month Day Year <br /> { t signature r <br /> Transporter 2 P nl pod Narrie <br /> 18.Discrepancyrr��1I ! ❑Full Rejacrion <br /> ❑ LJ Residue. . i 1 ❑Partial Rejection <br /> tea.Discrepancy Indication Space ❑ QoanUty <br /> Manifest Reference Number: <br /> Us.EPA ID Number <br /> �.1 Bb.Alternate F 01111(or Generator) <br /> J <br /> Ca <br /> Fakaliys Phone: Men Day Year <br /> c.SignW <br /> a re of temats Fac I (or enerator) <br /> CD 1 g Hazardous Waste Report Manegomeot Method Codes(ie.,cedes for hazardous waste aeatmant dlsp3sal,and raycfing systems) <br /> 4 <br /> 20.Designated FaeilNy Owner or Operator.Certlacation of receipt of hazardous materials covered by the manifest except es noted in Itsin 1 Da o ay ear <br /> 5!gna re a- <br /> nnted pe Name <br /> EPA Form 9700 22(Rev.3-D5) Previous editions are obsolete. <br /> GENERATOR'S INITIAL COPY <br /> LO 'd L 1;:5 L O LOZ EZ Int O 161991 60Z XEd 10d 34 NVA <br />