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<br />- � -- -- �- "� "'-"""'""'"'"'" �' - ' � - " Form Approved. OMB No2050A039
<br />UNIFORM HAZARDOUS 1, Generator ID Number' � 2. Page t of -3. Emargen<y Resp nse Phone 4 Manifest Track ng Number
<br />WASTE MANIFEST � ,A W � R 1 � (•) � � 1 t; - r �'
<br />5. Genar l Name antl Mailing Address General is Sue Address Q(diderent than mallNg address)
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<br />Generator's Phone: tdi`>`a'a ��:d<.27 dj ��{',('.,Tfj�j y-,,,
<br />6. Transpoder i Company Name f''"' YJ. 4.� �
<br />�"'�+")g"ifJ itiirFdb'Q�iOPd����lT'rpL �(�pt u'lu� U.S. EPA ID Number -
<br />7. Transpmfar2 Company Name U.S, EPA ID Number
<br />.?C�rd.La.ed€C�r ;�`sdr{J's+�RY.3Y s`f4;',1 4�;€;.
<br />8. Designated Facility Name and SgeAddress
<br />*(�� fr°-,g,(':a.Cz[:FRj�,(sT, iPc�, � U,S. EPAID Number -
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<br />Faciliiyrs Phone: (f=���?1:: F_?_tkvk2ti ;� � (i C7 fj () Fy ;;? ], j_ ry �>
<br />ga. 96. U.S. DOT Oascrlplion (including Propar Shipping Name, Hazard Class, ID Number, 10, Conlalnars
<br />HM and Packing Group (if any)) 71. Tolai 12, Unil
<br />73. Waste Codes
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<br />75. GENERATOR'SIOFFEROR'S CERTIFICATIONflherebyd cl re that the conlen(soflhls cons gnmenlare lully and accuralefydescnbed above by the propershipping
<br />name,amare classifed, pa kaged,.
<br />marked and labeledlplacarded, and are in all respects in proper condikon for Iranspod acrgrding to applicable inlernalienal and national governmanlal regulations. II
<br />ezpod shipment and I am the Primary
<br />Ezpoday I cedlfy Thal Ne contents of this ionslgnment wn(orm h, Iho terms of the attached EPAAcknowledgmenl arConsent.
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<br />I cedify Thal the waste minimization statement identiued In 40 CFR 262,27(a) (f I am a large quantitygeneralor) or (b) (i(i am a small quantity generator) is We;
<br />Gpnerarofsl0fferors Pdnledffyped Name
<br />Sltute .`1J � Month Da°^y'�3 .
<br />/Year]
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<br />-a atonal Shipm nls �
<br />� ❑ Import fo U.S, - ❑ Expod from U.S. P
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<br />Tran p d rslgnalure (for oxp hs only). � 1
<br />Date leaving U S _
<br />w 17 TmnspoderAck owledgmenr ofR Ipl ofMa(en Is ;
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<br />� Tran�poderl PriniedRyped Name � Sg lure/ /
<br />'' r � / Month Da Year
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<br />da Transppder2Pnnl dlfyped Nam �. ;�yf '4-/ f,Kr'.,
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<br />� _... -%>(/r` H/ 1(; (�. ;�� -. g9 !� - Month Day � Yar
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<br />18. Discrepancy v_ � / i - ,,,`_
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<br />78a. Discrypancy lndiralion Space
<br />❑ quantity ❑Type ❑Resitlu�
<br />❑Partial Rejection ❑Full Rejection
<br />�' 186, Allernale Facility (or Generator} Marcfesl Reference Number..
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<br />� U.S. EPA ID Number
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<br />Facility's Phone:
<br />� iBc. Signature of Allernale Facility (or Generator) � -
<br />- � � Month Day Year
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<br />y19. Hazardous Waste Repod Management Method Codes(i.e, codes forhazardouswasie treatment, disposal, and recycMg systems)
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<br />20, Designa(ad Facil7ity Owner or Operator, Cedigcalion of receipt of hazardous materials wvered by the manifestexcepl es nQed In item lea - - -
<br />PrinledRypeylNa a Slgnalme
<br />Month Day Year
<br />PA Form 8 00-22 (Rev. 305) Previous editions are obsolete..11 - � II I -
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