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r , Form Approved 0 <br /> typewriter.)' b:Maar aC Teack)pq N der <br /> Please print or Type (Form designed for use dr.elite(12-pitch)typ , ) 2 Page 1 of 3 Emergency Response Phone': <br /> Generator�IQ Number , ,7 ti s r; <br /> UNIFORM Hp�AItDOUS �': . f <br /> WASTE <br /> NkANIFEST Genarafots SiteAddress(if`differ.`entthan mafiing address) <br /> 6 G nerakpr'sNaman1�11iniddress <br /> r a 3 n <br /> US EPA lit Number <br /> Generatos�hone:. <br /> 6 Transporter 1 Company Name <br /> ffA� ar f,-5th eta <br /> :S"b EPAIDfVumber <br /> 7 anspbbrtei2"companyName:.,, <br /> IQ umber g <br /> 8 Rgstgrtaedfcllit�atarjdSrtekddres <br /> - <br /> �,t r � �r <br /> FacifEky s Phone 10 Confarners 11 Total 12 Unit; }S.Waste codes <br /> Pr per Shr to Name;hazard Glass I➢Number Clua.11 Wt Noi'.. <br /> 9b U S p'OT Descnption(including. op PP 9 Grp;. TYPe <br /> and Packing Group(if any}) �� <br /> MNt <br /> D <br /> IL <br /> 4 <br /> 40.1 <br /> 14.Sn��iaiarndl�ng instnsct�ons antl Rddittonat information =r aaj „,fi ,a <br /> 5 :r eft , <br /> nmeni are fully and accurately described above by the proper shspping'ramel an �}ns Mary <br /> ; <br /> OFEEROR'3 GER7lFICATION I hereksy,dbclare that tk�e centants.of this cons a lidakle international and natjonal go"vernmentaI regular ons;if export sh p <br /> 16 :`GENERATORS! <br /> r ed and laberedlplacarded and.are m air respects In p"roper coiidlttorrfor trari6port a6cordPP <br /> k of this corlsi nmenk conform to tha terms of the attached EPARcknowledgmeitt of cortsenf <br /> Exporter,i cerktfy that tale contents,, „9 Mo tfr Q Year <br /> if i am a small quartktiy generator}is true <br /> I certify that the waste mEmmizaiPi...... ent identified rn 4f1 CFR 282,27(a)(rf l sm.a large gpaptity gS gnatuoe or " , r <br /> Generato IT 'd <br /> 0 Export from U S. Pork of entrylexit. <br /> a"16.Infernatronal Shrpmenis impaftto;U S. Date ieavif g US., <br /> Trahsporter srgraiure(for exports anM: a <br /> 17:rran5porterAc.knoMedgmentofRecerptofMai, its nkh pay (oar ' <br /> Signature �: <br /> Trahsparter 1 PTinidlTyped Name� ' <br /> Month ' Ray Ye <br /> Sigriatore (' ars f 4 �� . <br /> 4 Tran ;r.0,2 PdntedlTyped Name <br /> '. <br /> 18 Qrscreparigy <br /> Rsr0 Full ReiectEgn <br /> Q edtke ❑Pattral Reieciiers <br /> 18a Qlscrapancy Indicati i Space Givant ty ❑Type a ` <br /> anifest <br /> tll .Reterenoe Number: . if S. PRIQ Number., <br /> 18b.Rlternate Facj%(grGenerator, <br /> V , Mohth Day ,_" Y8a <br /> ►moi .Facility's.Phone: <br /> p ty(orju <br /> Generetor) <br /> 18c 5ignattkre of Atkem 4te Fac li" <br /> stems <br /> `1 g <br /> Hazard Wesie Report Management Mi Cod (i a codes fqr hazardouswasts tteatment disposal,and we 091 systems <br /> } 41 <br /> 2 3 <br /> 20 Designated FacilEiy Owner or Operator certification of receipt of hazardous main�ais covered.by the m3gnsinecept as nded iii Item!$a <br /> Month Qay Ye <br /> Pr�nt2dlTyped.Name <br /> FRAf SPaFITE 'S CC <br /> EPA Form -.22(Rev;3 05) Prayl: , editions are obsolete <br />