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Aug 07 2015 4:34PM HP FaxLadds Marina 2094779585 page 2 <br />Please print or tvve. (Fol de f d for use on elite (12 al1Cmtwv, : r3 <br />Form ADDroved. OMB No. 2056-0039 <br />Crny 1 'fl Oriu•L�L �rcav, rw) rrevror eamons are oosorete. GENE R'S INITIAL COPY <br />1A, 4 ►r.'� w .,nkMAI <br />UNIFORM AZA 0111 <br />1. Generator Ifl NumCer <br />�r <br />2 Pa9a 1! <br />� <br />S. Ems <br />� t <br />pes a 1 Ndrn <br />�a�l <br />WIT �r►r�I <br />S Oefheraytor9 tl " <br />Jkidress "y1 rj <br />' "' Generat Atldress {t d lferent tthhann mat ng address) <br />•.311 <br />W t. yy <br />L � r'QA S. 4.lal � <br />�i�, <br />EGL <br />")''11:1 'Ncklev ; nve Way <br />:.,. <br />�'� <br />Tree ooar��rr ompany me — <br />U•S. EPA ID Number <br />T. Transporter 2 Company NamepA <br />ID Nu mbar <br />1 <br />rr—AITU rW0 t14Tit fi �IT <br />8._4esitY-caled FoOdy Nares and Ste Address ii, -9F w <br />Ift OISE UX U.S, EPA ID Number <br />VIS <br />W*— 44; � f xt' <br />t,t�t1� �'�i^�'f , i 10 <br />Faci6 Phone: <br />9a, <br />96. U.B. DCT DescrOm (Mdtrdng Proper Shipping Na"ne. <br />Class. ID Number, <br />10- Contallners <br />11. Tula <br />12. Unit <br />HN <br />and Pawro (Coup Many))No. <br />Quantty <br />Wt1Yol. <br />13 vtsle Codes <br />Type <br />CX <br />1, tatwiri $p£y•"y�il S.if�.96t." �A' y .r y <br />r'^I <br />T' 1�k J�, `r. <br />~ <br />1 <br />te�il�h•rr <br />� <br />y 6e>• "j7t'fPl}ii°DFfr EI� <br />1, <br />6• r <br />a <br />3. <br />'r� 4 <br />4- <br />14. Spedal Handing Inst uct ons and Additional Irformatiotl <br />Sif,_..- <br />�-, i f�'r.',_.,.n <br />I x1`7 '7 3=�* 5 <br />F $_s <br />".19±1 lath <br />1W11 <br />5. GENE"TOR'Sf13F ERDR'B CERTIFICATION: I hereby declare: <br />ON oantefue of this oonsignmant ere folly and accwately described above by tha proper ahlppfng name, and areclassified, packaged, <br />Maiand IabetedrplaCmrdacl Arid ani -m all respects inpmoper <br />' far Varw facco ding to applicable international and national governmental regufabons. if export shipment and I am the Primary <br />fxpor `t 4MI[y thatbi contents of riioiri td this consignment cd <br />lerm4 of the eMbhed EPAAokWwiedgmsrd of Conse d. <br />I cerflfy Iheti A waste minimization nbs nentidenbliadl h4o CRR <br />a small quantlty gsnerafor) is frura <br />" <br />0 re Plin ped Name <br />Signature <br />Moto 1 YM <br />� <br />- <br />..r <br />16. International Shipments <br />❑ Impart to us. <br />EIExport from U.S. Port of entrylW: <br />Transporter signature (for exports only): v .: <br />Date leaving U.S.: <br />'17.Trarsptvterllc1moMedgrnerrtofReceiptoFAtetekt y •.� <br />nsporT� NamS <br />ypad <br />Month Day <br />e <br />12 17— 111 <br />JITITmnspoftr <br />z FWMIVPfW Name , <br />b: s .".<! <br />Month Day Year <br />18a. Discrepancy indication Space Ouanti ty <br />• "t_.J Typfi' � ❑Residue iJ Penal Rejecticn <br />❑ Full Rajedan <br />VlanifestReferen Number. <br />8b tamale ,aor�ily{pr6eneramr) ;. ,� <br />� u U.S. EPA ID Numb <br />LL <br />Facilll+s Ptionec ' : ^.; <br />'•" '.. rf <br />u <br />18c. Si9wfure of Fedlpf (or neralor} <br />a <br />Mmth Day year <br />J�f <br />19. Hazwdous;VWReportManraoementMethodCod" a codes <br />Mis waste hbabnenl,dispsial gndrecyd,gsy,*rns) <br />LU <br />,. <br />2. <br />3. <br />4. <br />20. Desigaaied Fsdrihj Owner eY Opmlor Certfcadon of receipt of It <br />malenafs covered by ate ru dest except as Hobe in hem 10e <br />emiftivTypec (carne <br />hi <br />mWW <br />Crny 1 'fl Oriu•L�L �rcav, rw) rrevror eamons are oosorete. GENE R'S INITIAL COPY <br />1A, 4 ►r.'� w .,nkMAI <br />