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—se or.ype.(Form destgned to,ase on elite 112-pitch)typewriter.; <br /> 1 Ge ;atcrtII,NumbSr r �a Form Approved.OMB No.2050.0035 <br /> UNIFORM NAZAR€OU5 ?e 1 of 3 E.reroprry Response Pt:rne 4.Manifest Tracking Number <br /> WASTE MANIFEST <br /> -t. 093639474 GBF <br /> 5 General ;Jame a-d i �J. <br /> n lurepa Ganeratre'st <br /> Si eAdaresa fif dit(erent Star,rroati,.q addressi <br /> Generator's Pnone' ` <br /> r <br /> 6.Trarsporfer 1 CrmparV'4.eme <br /> u S EPAiC NaMbe, <br /> 7.Tr nspnrter)Crmpanp Name <br /> aJ 5 EPA IG Number <br /> 8.?esignatec Facirty Name and Site Address <br /> .. LIS SPA O NL nrcer <br /> racilih✓'s Phone: <br /> ga gh US DOT Description iiacluding Proper Sh, ry Name,Hazard Glass,Ib Numcer. <br /> HAS and Packnq Csrrtup i+arty�. 11 Total 2 Unit <br /> p Qua r,r, or <br /> 1" N;aste Cones <br /> Cr <br /> 0 <br /> Q <br /> Ix <br /> ut <br /> Z <br /> LLA <br /> i <br /> y <br /> 1S-e; ln- ons and Adult r <br /> 5. GENed and RbeledpEROR'S CER71FiCA7lOFl: i hereby d2clare that the contents of=,hie consignment a ° :, a I.:urately described above ay ire > m,ping name.a,YJ are classified,packaged, <br /> market and IabeEed;placarded,and are in at respects it proper cordttion for transport according io apokah,E w,errat ,ta!anr national vernmenta€rigor ,ipr, " <br /> Exporter,i ca.ify that the contents a{this consignment contgrm tc the ten-A Y(he sitaohed EPA Ackroavtedgment of Consent "expAn shipanent and an Cre Prraa y <br /> I certthj that the waste minimisation statement identified in 40 CFR 26s 7,a;ti`I am a large a ant h;;F r -rt G,r iL ;f I am a smn:rall pua <br /> venera#orsrOffa crs Printedflyped Nane tY generator,,c true. <br /> futC71'th bale .."ear <br /> ti's► ( Y <br /> t <br /> t <br /> _ o :ternationai Shia en^,; - . <br /> E" L.,.I ImOort x U S <br /> 'Transporter Signal t cr e.+ports pnfy'r. 1 Export front U S Pori of en !axil: - <br /> �, <br /> Date leaving U.S <br /> — ---- ,� <br /> � 1 .T� p ne ��krnpxpdgmpn;cfRece ptaf FAaterrp� <br /> arle <br /> Z / ��E d f ./"ff t �� rte .._ Urn�:h Yea <br /> 7r <br /> Q .ra goo er 2 Priv! ed Nan,e r <br /> Morti2h 6uxr ti'e <br /> /Discepanr; <br /> a <br /> --I i•"' �_Partial RcieclCr —i Full R_I_:tw <br /> lot. ItemateFaciri :,.yr.;=. LL�;+ :Refaenc23umint, <br /> J <br /> J <br /> uL Fa i1y's Ph e <br /> W F S n a u of Afte nat8 Faor'6ty(kr tieneratarj <br /> `X Month Day Year <br /> z <br /> "v Fez �t <br /> Reonn'v+era ei r <br /> g.,err_Met" "„des ;p. q <br /> codsa for hazardous was dispoSal.sac recycling systems: <br /> 20 Desto�ate ..iertifiCalfon pf ^riot of hazardous,ma6en+5,' , t <br /> Printed'Type l-,�- r o Bred fv the man{te_t exCE Pt as r e <br /> r Signature __ Month Day r.. <br /> EPA Form 5700-22(Rev 3-05l Previous edrtions are obsolete. <br /> ' .w'=[v.3 k"§+�'SE t"'is>,Ar r•.^a.4`e't`. i"Y[„'#*`d""MRi A.`P"�SP a tiT`N`4"d`"' teff ij^r§83FC°.c +YL g <br />