|
icl'ease tint°or Type,.( 6rm designed for use;on eJ to(1� ,plt�h}'}ypewnter.)...`:,.. FnrmAppro red'. M6 N�,
<br /> U(1fF0RIN HAZARDOUS 1 Genefatorp bjnbt1 2ag1 of 3 ErrergencyFSp4nse Photie '14.,"",M�faTr�k m�r�
<br /> WRSTE tfAANlFEST ,_.
<br /> 1,-�.1,�.�,,"�,�.:�,��""....."��:,..".
<br /> JJ .
<br /> 5 Grtgr&tto� �laedl� Addresa)r f,N , }=,{ttt Gesie�atorsSltaAddrsss(ifdifferentthanmailing'addiasa)
<br /> 2.
<br /> yy�., :ti;.
<br /> �N..-5� , '4 1� 1
<br /> GeheraforsPhones.: - -_ .+ ",.:: ,,, '4r .r;. ,
<br /> ti Trarispntter 4 ohipa y Na n r t , u 6e
<br /> ," �! - a y .
<br /> :°
<br /> r AI
<br /> FIX "i ,..,,t', ,..r_. <' .:1�. ,`.; '-.✓f S3P�'f,jS F' �.-
<br /> u �
<br /> 7 ar sporter 2 CompanyNama ; ::, ,-:;�, . .'. ,.., ..�k� - ,,�.�-;m,-1", -,"', .. :-,� 1. .
<br /> a # U. E A Il?N bei p & wy
<br /> w f �' #' t { €� �. - ` a'," r� s{.,.,it€�7^ t a r . G
<br /> 8 f�esi ed l de€t€t�rpVfime artd5€fe�Acf.. L {J 5 EPP d fur berg .
<br /> r� t i,O�5
<br /> ,�.r� -� �
<br /> FaCili 'Sh03]e '1 Sr Y t t 11 z u r f - t s r '.91. .p:: r [ -ff -
<br /> 9a �,9b U 5 f?OTbescript€on(includ€rg Proper Stiipp€ng Nama Hazard Class ii7 Number, 1U 00TI ,rters 11 Tota( 12 Un€t; 13ll'Na to Cotles
<br /> PM "and Paclung Group(rf anY?) 4uant€ty WtNbI.
<br /> No :Txge
<br /> la rk 3� ,srr �'t"�a5w:, v3 '�r w .vara ra 1
<br /> 1g p ;„�
<br /> _ %� , ( ':'r
<br /> r.
<br /> [�
<br /> . ,
<br /> .
<br /> .-.. . 1. .
<br /> . _
<br /> 1.
<br /> 3i
<br /> 4,'
<br /> t
<br /> ,. ,s
<br /> 4
<br /> ;:
<br /> 14 ,pie a� to dl rlg lr st Vons antl Addltlonal lrrfarmaUan f �,,
<br /> ,>
<br /> r> ,.
<br /> L ,
<br /> 9 (R
<br /> t. 4.Y.iL an5 FY L. .k a� �'�/:,a t t. „ ::.
<br /> ..
<br /> 15 G�3I):IigTORSIO FSR we",oERTiFtCs TION 3 he eb deelarethatthe contents.I tf is carfsf r}rirant are"fu11,'and accurafel ,escabsd.above b'the ro er=shi €n .name and are:cliissifletl acka ad
<br /> ,. , -'> , ,. .. 'll, t.>Y 9 Y Yd Y.,, P P PP.9, _ .. ;_
<br /> mar eda dlaheledl is rdad andarelna1i,res ectsiin Fo er:condition€o"rUans ort'ascordin ta." Iicablelnterriadotiaf-ard•4tlonaF'ovemmental"re IrlaUoris€Ifax crtshi mentana.- mthsPt€ma
<br /> P , 0 s � p PP P 9 Pp g P P a ry
<br /> Exporters I certl€y ttraf the ,tQpR of,ps oensig melt rarltorm to the farms1. i of the atfacfietl EPAAekr�owledgrtlant of Consent
<br /> l ce ff ina the u rife minfmlzation stat anent Ida 'ed In k CFR 262 27(a} fi am ala ge quarrt€ty generatar)o"rp(b)(If I atri a small uantibj gen... r)Is true
<br /> 1. Gsnerato�sl0tferors+Pn e lypeame 5€gnature o tt�h y Yew
<br /> 'x ,p � ..
<br /> 18 IntematlonaI Sh€p'ments
<br /> ❑trhm t to 11 S _ Export from'U S Porf of entryfexl4
<br /> Trarispoi ter slgnatn[s{f ." , offs only} bate l&av€ng t15
<br /> 17 f�ansporfarlcknvwledgment,of Rece€pt of,Matenals ; v'
<br /> �A
<br /> O Transporter ti n dF 11 e N n S€grip e.. _ dt5t i pts Yea
<br /> �✓
<br /> Trans�of. 2 PrnntedlTyped Narne i i 't 7, ': ,r1 S€gnatare r r- `i' ersth Year
<br /> r
<br /> f8 drscrepancya i J
<br /> 18a I)rscrepancy Indication Spaee 4uantl T e r
<br /> 0.
<br /> ty :. yp ,- Res€due Pa€tial;f#ejecUon L Fufl,Reject€onAll
<br /> fanrfest Reference Numtier
<br /> 18b A#teYnafeFacility(orGeneratorJ 11:;5 EPAIDINumber
<br /> V
<br /> >� 601€tysPhone „
<br /> 1. I ��
<br /> 18c 5€g,.",,:�:�'.","",,Yiatur'..,.,,.a'of'Al�ent,.�;:,,'.�,��'L.,ate,,�F""aci ,,� , . :: .... . 77
<br /> k'.lity{or Geriet--ator) ,,,�, ,., ., _ , -?, . . . . . . . Month oa""� Yehr;
<br /> Q1.1111,11
<br /> 19 Hata'
<br /> us rdous l✓(aste Report Management,Melhotl Godes(I a codes'for hazardoers waste treatment dasppsa[acid req�y !ng sysfems�
<br /> 1 2 3 4..
<br /> 2G designated Fa lrty Owner or Operator CerUficat€on of rece€pt of hazardous rnatenals covered, Ure rriamfeshexoept as octad in Item 98a
<br /> PnntedlTypedName: :.5€gnature': Month ,-D.ay ,Year'..; .
<br /> EPA Farm 87.00 22(R�v 3 05) P[evto�s edit one are;obsolete " TRANSPORTER':S C(3F?X,
<br />
|