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Pf�-a�ie print or". 111111111111111 Form Approved.OMB No.2050-0039 <br /> UNIFORM HAZARDOUS 1,Gororat0r ID flu ter Z Page 1 of 3.Emergency Rosronse ftn;rest Tracking-Number <br /> WASTE MANIFEST 11 <br /> 5-Gene at N and Mw"mdress- I n13 aaga&FLE <br /> Generator's Site AddreSs(it differarit than mafling addrm) <br /> "P o <br /> Generator's Phone: i4 L L, <br /> XS&arisporler I COMO y Name <br /> U.S.EPA <br /> I jTn sl,�r 2�co mpar�e <br /> U.S. Nu <br /> y 711',17�V � S.EP N <br /> a Ob's Phone: <br /> 93. 9b.U,S,DOT Description(including Proper Shipping Name,Hazard Clots,ID Number, 10 Containers 11.TOW 12 und <br /> M am Paclung Group rd any)) Na. Type Quantity ffl.ftf, 13.Was,o Cadet <br /> waste, ilauld fg <br /> 0 <br /> 2, <br /> LLI <br /> 0 <br /> 3, <br /> 4. <br /> 14,Special Hanillirig instructions and Additional Information <br /> 1 110524 N k; I Is U W a 5 7 P <br /> -7- <br /> 15 UNERATOWS110IFFEROR'S CERTIFICATION: I hereby dackare that the contents of this cerisignmem are fi*y am a=ately descrW above by the proper shipping name,and are dmified,packaged, <br /> marked and l eied.p€acarded,and are In li$MSP"in proper OmdifiOn for transport according to app6wbie international mid nationst goverrirriental fegulAtiOrm.ff airport shipment and I am the Primary <br /> Exporter I ce"that the conte of this consignment oodorm 10 the jorm of the attached EPA Ackrxiiiiiiedgment of Consent. <br /> I-earthy that the waste minimizaron statement identified in 40 CFR 26127(a)(if I am a W"quaribly generator)or(b)(#I am�a small quantity ge—aldr)is rue. <br /> Go <br /> Month Day year <br /> IS <br /> nspQrIer signawre(V exports orily): Podf.U.S. of entry/exit <br /> te leaving U.S.: <br /> import to U'S' ❑E <br /> Z Tra <br /> CX 17.Transporter Ackeowle<lgment of Raceifit Of matanais <br /> UJI <br /> f- Tr-arspoiter 1 Rt W- yped Name <br /> CC k si;naturel <br /> 0Month Day Year <br /> CL r- <br /> in <br /> spoiler lure Month Day ear <br /> M <br /> 18, <br /> 9 Ba D ser <br /> ancy Indioulion S LJ Quantity E]T,, Resid ElPartial Reoction Full Rejection <br /> I&Alternate Facifily(or Generator) Manifest Reference Number <br /> U.S.EPA 10 Numbe, <br /> Facility's Prone, <br /> UA t8c,Signature of Allemate FarAAy(or Generator) Month Day Year <br /> 19,Hazardous Waste Remo Management Method Codes(i-e,,codes for hazardous waste treatment disposal,and recycling systems) <br /> 2i --- <br /> 2, 3, 4. <br /> LA I <br /> 20.Designated Facility Owner or Operator:Cerlificatiort of receiptof hazardous materials covered by five manifest except as noted m Item 18a <br /> Signature Month Day Year <br /> U' `A 7— 1 to I o4l Iq <br /> EPA Form VW22(Rev,12-IT) Previous editions are obs6lete,' ESIG D FACILITY TO EPA's e-MANIFEST SYSTEM <br />