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Please print or type.(Form designed foruse on el(te 12 ch <br /> UNIFORM HAZARDAUS Number -Pru anter) <br /> ..........Generator iD Form Approved.OMB No.2 <br /> WASTE.MANlFEST 2.Page 1 of 3.EmsrgensyResporrsaPhorte 4 @#anifost7 N <br /> till fti4>r Jf `~; s umt�r <br /> S.Gene amt Haling Address G �+:tl 14- <br /> 01247-In <br /> JJ <br /> enera6ors Me Address(If ftirent Oran7itaiing address) <br /> STCtCKTC1A1,Lig QjA.VC-R WA--,- <br /> Gds Phare: 1!111� WNAAA +Ad W WQ <br /> 6.7rensporter 1 Company.Name <br /> ' George w. IE M, �E�-, <br /> .'t <br /> U,S.EPA ID Nrimber ' <br /> f <br /> 7.Trensportar2CompanyName ? filet }�I t <br /> 8• 1V o Y .2 01 U.S.EPA lO Number f <br /> Designated Faddy Name tend SleAddress <br /> - . <br /> Ips U.$,t3PAID,Number <br /> MUMAaetn. -ENVIRONMENTAL <br /> I KEft,�F?. Et7,C.h�.WXq- <br /> SPhone ,,..;.: rHEAtTH DEPARTiVIENT; ' <br /> ga. 9b U.S.DAT Desalptron(Inck g Plop-r ShippingName Hazard.CIM 10 Number" <br /> NM. and Pac[pngariY)) 10 Comainers <br /> 1• s., , T 11:7 12. nO 13.Waste Codes <br /> Y Quantity <br /> U <br /> WtNol. <br /> O t itG iL7grUt WAS* 01. ('OILY., t 'j?EM sl <br /> �?taI P <br /> AM <br /> 2' <br /> 3. <br /> 4. i <br /> i <br /> 14.Sped Handing Insbun�ons ardAddOienaf Irdamation - <br /> 1 171 <br /> WEAR t3LCA.-E-, <br /> �. <br /> 15. t;ENERATOR'SIOFFEROR'S CBI'll TiFICATIGN:t hereby declare that the stents of this corn nmeat # e7/ 1 <br /> marked and pfacarded,and are in al re pacts in proper condition for ba y and accurately descdbat above the 1 <br /> Expater,l certify that Sia contents of this consignment conform to Ne.tams of the nached Epg te applimNe and national ProA PPing'name,and are cte ' <br /> I�Y that III waste minimization statement Iden8lec{in 40 fR 28227{a,{d I�n a of Ccnsent g° eni�regWedons If export shipment and 1 am Ora Primary <br /> Gds P- yped me �--•:r 9uanOty genarato►)or(b).( 1 am a small quantity generate is hu.- <br /> Signature r f <br /> } MonUt Dei Yea <br /> 18,�temetbnat Shipments (�( /�•: � ,` " ` r <br /> Transporter <br /> signature(for exports orgy). Export from U.S. Port of errtry/axl: <br /> 17.Transporter �of Receipt of MateriNs Date leaving U.S.: <br /> Transporter 1 <br /> yt 1Namrf41 ,e, Stgnalure r <br /> Transporter Name <br /> Month Day Year <br /> YPa1 <br /> < _ Signature <br /> 8.lAscrepancy Nktdlt Day Year <br /> 8a.Discrepancy Indication Space -. _:... <br /> Q Quantity ❑Type ❑Residue <br /> R LJ PatOal Rejection ❑FuO Rejection ' <br /> J <br /> ib.Alternate"Illy(or Generator) <br /> Manifest Reference Number <br /> U.S.EPAlD Number ' <br /> 'alrlys Phare: <br /> c- gnahrre ofAlerrwte Faculty(or Uenerator) 1 <br /> Month Day Year <br /> Hazardous W/este Report MManagemenntt Method Codas(r.e.,codas r0r hazardous waste treatment disposal,and rely rrgStems) <br /> rte-- f f f 2 3. 4. <br /> Dedgfia l facMy Oavner or Operator.Cartilca8on ofnee I t of ha <br /> yt>�Name P zardous materials covered by the manifest except as noted in tem 18a <br /> Signature <br /> Month Day Year <br /> n$700-22(Rev.3-05) Previous editions are obsolete, <br /> TRANSPOII f t=A'S COPY <br />