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Please print or tppe.(Form designed for use On elite(12-pitch)ty writer',} <br /> UNIFORM hAZARDOUS I Generator i Number <br /> 2.Page I of 3 �(Drrr APll Okl$Na.2050-0039 <br /> fall <br /> WASTE MANIF T4.Manliest <br /> 5 NWft and MaillingAddri <br /> 0AWft*r9Wi5=S11dreSs ,,711—,.-, <br /> 1,1 7- 9 91 JJK <br /> 01369 <br /> (If d'ffel thenni add. <br /> Genergmra p <br /> 6 Trinsportef I Coni <br /> U.S.EPA ID Number <br /> Tranqpori—2 Com --"t- <br /> U.&EPA I[)Nur,rbelr <br /> F.Designated Facpy..........d tkA A D -9 <br /> 51 'V <br /> ENVIRONMENTA) <br /> Facility's Phone; T7 A <br /> 9a- k.U.S.DOT Description pndUCFWV pi$hp*l�Name, <br /> Wd Ped"Qroup(fr any)) hazard Class, 0 Number '10.Contain l �.btal 12 Lill <br /> No. TYPO 'N3s:*vl,Cci. <br /> Ou�nljl <br /> ............. <br /> 2. <br /> 14.Spe H <br /> and Awli irrormation <br /> 4 <br /> 15 GENERATOR' <br /> Gt 1TtffCiUlt1M: i herebydedars <br /> M.'Inklild and labnkidip�jjcsrdl and a ill al 11 conegrImaint are f)Ay and a—mly described strove <br /> re 1(i al resll in PMP8r condition for transW a=rding to applikable International aric national goyem by Me PrOW shipping name,and are lase fled,packaged, <br /> EqWar I neffly that the co*nts of MIS 00"WIMOnt Wfll to the terms of the attached PAA&nrvved9lrnw of Cof-isent. <br /> I-rlgy dlat the wade SMISITivrit ldended in 4 CFR 2Q.27(a) ,atia (ner"91 r0gLIak1s-If Slxplort shipment and I am the Primary <br /> am a large qui generai ib;(iff f atn 3 MIAqual generator)is me. <br /> LJi oort tous. <br /> Tranal ❑signaturp(�)r expprt�onjy): U.S. Net6fenl <br /> 17.Trani Ackn ment ;el OT Materials N16 Il U.S.: <br /> -Tr8WWttr I Print yped Nam i <br /> Year <br /> rairil 2 Prin— <br /> Month NY Year <br /> 18.01scri <br /> Isa-Dil InufCatlon SpaceOuandty 17 Type Residue ❑Partial Rejeujun Ftill R*cb(�n <br /> 18GAR&TISM Fa0fily(or Generator) Manifest Reference Number <br /> U U.S FPA ID Nurr�er <br /> FacoVs Phi <br /> 18c griature of <br /> Month Day Year <br /> 19.Hazardous WaawlebOd Codes(i.e.,cvjes;or haZBrl W <br /> LU 1 aste Vesirwilt,disposal,and recycling syqeri,j <br /> 4. <br /> 20.Dompriated Ficli uwner or operator:Cernr_,�.n of <br /> Pii ypod Na.. receipt of hazardous materials covered by this rnan!fliiq&xcql nae,l o lten 10;a <br /> Stynatura <br /> Oath Day year <br /> PAForm Bl G-22(R <br /> GENEHATQ8'$ INITIA� COPY <br />