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�— 1111101111111111 Form Approved.OMB No.2050-0039 Please print or type. pProv� UNIFORM HAZARDOUS 1 Generalor fD Number 2 Pane t of 3 Emergency Response Phoned.Man'rfost Tracking Number WANE MANIFEST ''''i �`.� 1 0/2494828 FLE 6.Generators tdarne and Wil#V Address gyrator's Site Address()t different than mailirxd address) Gonerator`s Phone. 6 TranspDoer 1 Company Name U.S.EPA iC Number 77 i.Transpoder 2 Company Name _ US EPA ID Number ix) Y't h ae— 1 CA A 0Q 0 95-4 Z 2- 8 Designated Facility Name arW bile AW0.5s f i, <. U,S EPA fD idumt ec yur%- : Facility`s Phone: a .�;. ga. 8b,U_5.DOT Desoaiptbn(including Proper Shipping Nang,Hazard Class,IO Number, 10.Containers 11,Total 12,Unit 13,Waste Codes !tM and Pw*ir g Grow(f n,)) No. Type Ouantily Wt.N.I. Cr , q t id[ 3. ($ I 4. I i ,4 Special Handling instructions and Additional information 4 1>5, GENERATOR'SIOFFEROR'S CEftTtFtCATION:I hereby declare tt flee contents of INS consignment are fully and accurately described above by the proper shipping Darns,and are classifiers,pac+,aged, marked and bbeledIpLicarded,and ate in 90 respects in proper condi icin for transport aecardaN to a International and natoinal governmental regulations,.If export shipment and I am the Firmary Exporter,f certify that#t cements of Wis consignment oor*rm to the terms of the atfadted EPA Acknowledgment of Consent. I certify that dee waste minimizat as statement identified in 40 CFR 262.27(a)(d I am a Wrge quantity generaWr)or(b)Cf a ll quantity generator),*true. Generator' Ptlt+WTyped Name r/ Signature Month Day Year J 16,l ematiml$hrpmesit9 0 Import to U.S. ❑Exp=ort from U.S. cot of enuyl.rt �_— Transporter signature(for exports only): Date leaving U.S.: c 17.Transporter Acknowledgment of Receipt of Materials LU Transporter 1 PnntetftTyped Name Signature Month Day Year LU M = Transoarter ,m yped Name Segnattre.. ..... a Month Day.... Year I&Discrepancy r�1 IBa Discrepancy Indication space F I Quantity L.._1 Type L_S Residue 0 Partial Re}ection �Furl Rejecbom Man4est Reference Number: 18b.Alternate Facility,for Generator) U.S EPA ID Number U Facility's Phone: WI Bc,signature of Alternate Facility for Generator) Man t Day Year 1g.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) d t. 2. 20,Designated Facility O.;.;o(Operator.Certification of receipt of hazardous mafenafs covered by the manifest except as rided in Rem 1 Ea Pnniedqyped Nam Strati e rh Clay Year �0,/gtrlf- EPA Form 87001-22(Re .12-17) Previous edition, re obsolete. FACILITY TO Pea's e-MA IFEST SYSTEM