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Please print or type (Ii6 designed for use on elite(i2 p pewdter.) <br /> UNIFORM g 1 r IO Nunn Form A 2.p 1(WASTE StANIFEST Errle�enc__y-R�espop, 4.MarntfestTrackfn Number <br /> . ,1j."1� ff <br /> 5.Generator s N iwulm <br /> GeneratoA Site Address(d ditiewt than mailing address) ' <br /> Vi <br /> QrV - <br /> Gen <br /> eraloes <br /> 6.Transporter t Company Name - - <br /> (�" �M U.S.EPA ID r <br /> 7.Transpor�r 2 14 <br /> Cempacry Name (...i EV <br /> U.S.EPA ID Number <br /> 8.Designated Facxkty Nana and Site Address <br /> U.S.EPA ID Number <br /> gaPhon _ . — `— <br /> Fdys9b.US.D01 Destxgun CmduinProper Name,iaz � <br /> (lass <br /> �dPar�ineC�OupCdanY ,tD rkur,ber,?? tO.Conmi,�rs.. . 11:Total _ t2 13.Waste Codes <br /> -unit <br /> 1.nGX) No. Type Quantity vvI <br /> 4: „ t; 1( <br /> O ( 1 <br /> Nut <br /> 3. j <br /> 4. a <br /> ENVIRONMENTAL <br /> 14.S , 111u <br /> ff,le <br /> 15. GENERATOR S/OFFERO.R'S CERTIFICATION: f hereby declare 01st Ora oontents.of This c onslrment are fidfy and accurately described move Bre t <br /> marked ard fab ed,and ars o eO respects in proper catdition for trans by proper shipping Hama and are classified,Packaged, <br /> er I ce*that the conte of gds P°d according m aPpBcahle finemaliar�and national governmental n gulagons.Nexport shipmentand lam the Pdmary <br /> Export consignment conIonn to Ore terms of the attached EPAAcknowledgrnent of Consent <br /> 1 ceNfy ttsat One wash minimdi 111'ement klenOfied in 40 CFR 262.27(a)(r11 am a large gaanitty geneMor)or(b)(rfI am a small <br /> Generatorst)tjerors pnn quantitygsnmatorj is bve. <br /> c t t` 9(ra Month SAY Year <br /> -•a 76.International Shipments <br /> t'° ❑importU.S. a Export from U.S. Pot of enWexit <br /> Transporter signature{for exports mOY}: <br /> 1Z 17.TransportaAdoawl�rrerd of of Materials <br /> Dei issuing U.S.: <br /> I Transporter : yped <br /> 0 T / h� D a <br /> CLI ''' : ,9th f/ <br /> Q Transporter 2 Printedi'fyped Nmne <br /> , ► <br /> Mi ;i <br /> Signature' Modh Day Yearj <br /> a / <br /> 18.�saepancy <br /> 1 <br /> 11a.INscrepancy indication Space ®tluantity <br /> ._... Type .. ..- ❑Residue - <br /> ❑Portal Rejection ❑Full Re)eCUon {. <br /> vp <br /> 18b.AKMple Fadfity(o Generator) Manifest Reference Ncxrrber <br /> jk <br /> - U.S.EPA b Number <br /> C FadBtp's Phare: . <br /> f <br /> 18c.Signature ofate Facility(or Generator) j1 <br /> .. Month Day Year <br /> (r <br /> .[1 9-Hazardous Waste pot Management Method Codes(i s.,codes for hazardous waste traah�irt,disposal,and recycling systems) e <br /> 2, 3. 4 <br /> 20.Designated Facility Oxmer or Operator.Certificafion of receipt of hazardous materials covered the manifest ax <br /> Name "� by sept as noted in item 18a.,—) / <br /> Month 0 <br /> S a <br /> t Fenn 870N22(Rev..3-05) Previous editions <br /> TRANSPORTER'S COPY <br />