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Please prin(or type, (Form designed for use onht (12�iitch) tyge4vitlec) form ApFravad. 01,41B No. 3050-60393050-6039I 1
<br /> t (JtItCOR i NA�p D0U3 1 C'anerata lD Number E Papa o! 3"title andt Re�lwrae Phone d. ldantrzsi rrocting Number M itA
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<br /> T Transporter 2 CompaoyName U.S. EPA ID Numbs r 1 7 —,
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<br /> &. Deslgnated FacAty Name and S'lteA,ddress r U,9• EPA ID Number
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<br /> ga, 9b.U.S. DOP.Desddpeon (IndudingProper Shipping hlame, Hazard Class, 10 Number, 10, Containers 11 . Total 12, UnI( 13, YYaste Codes
<br /> HM a adPadkingGroup.fifiny)) No. TYPe Quangry VaUNoI.
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<br /> �1q; Specjal Handing shudwns and'gddlNonaflitfomiabon
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<br /> 15. GEI�tERATORVOP�EROR'8 'cERTtFIcAT1oNi 1 hgrehy'dedare lhat.ihetontenis of this cons(gnmentlare Nllyand adcwately described abode by' the propershippirg name, aid are classified, packaged, '
<br /> nisi d and lab elad`placarded, end are In all (especfs in proper condition for trorisportaccording to appli�Ieintemallortaland national governmental ragulatlons, if exportshtphtent and I am Me Pdmar(
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<br /> Ex�torter, Fcertlfy. fthecoritetttsa s;onslgnmshtconformtogtelemtsoftheatlaohedEPAAcknawedgment :okonseni.
<br /> I 'cgrtify that ihe.wa e minirdzaWn slalemgnt identified in q0 CFR 282 27(a) ¢f I am a large quan6ry genetalor? o� @) �f I am ; ';mail quandry generator)is bue.
<br /> General ;/Offerors P ntedrlypedNama 't' Wtalure y . ? Moth y Year
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<br /> F, .� Impod to:u,S. ❑ Expod from U.S, Pott of entry/exit;
<br /> Transporter slgn00
<br /> alur (for expopsronly} . Oata leaving USA
<br /> plk� 17. ?ranspodergckn§4rledgmentoFRecaipEio�Malerials
<br /> f— Trans o 1 P ' t ed Name Sigtuiture g a Month Day Year
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<br /> 16. Olscrepandy ��—• -
<br /> -18a. Olsore6anoy Indlosdiri Space o Quantity Lliype Residue ' Partial Relation ❑ Full Ra)ection
<br /> Manifest Reference Number.
<br /> h 18b. Nternate Facility (or Generator) U.S. EPA)D Number
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<br /> Bc. Slgnahrra ofNtemate'Farigtq (oi Generator ; hto ilii Day Yesr
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<br /> 19. Hazardous YJaste Report lionagement Mee od Codes (1.040 codas for hazardous Waste treatment, disposal, and na ng systems) ,
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<br /> 2li.,Coghatsd Faaliy Ovneror:Operator.. Ced fcelion of rec4tof hazardous materials covered by the manliest except as noted ln'Item 18a
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<br /> PAf" &700-22 Rev: a.-"• Pr&oAaeditidns are oW(Rto:
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