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Otvle I2CV)-039 , <br /> Farm Approved ��� N <br /> C14 / a,MenSest r Nin NuS / 3 4 � <br /> -- y RMPnnso phone <br /> ,,..rQ� O 4 CIE N <br /> 3 Emero CY'fMn�� dress! O <br /> GO <br /> N - - n mailing <br /> � _ 2,Pa9B I of �42'�"`•� I tlra ad <br /> L0 t silo dress ld dBleren (13 <br /> O Please Pri'to <br /> r type. I Gtr,G Numtwr ,7_ $ 1 GeneratofB <br /> C g i 1) a a 1 <br /> UNIFGRM HAZARDOUS l) 1 7 <br /> WASTE MANIFEST IFOpN <br /> it = Nawand MalVlrq Addhin Cly, � 115 EPA IDNund- <br /> p 5 c'°i81 UFS t A R 0 p <br /> E 1400 N Mpt,ARTHUEPA F1 DR <br /> IRR C'fk 9'147B <br /> U.5 IG Number o 1 ' 4 1 <br /> O Iltl7N ! riU S <br /> AO nwalrs PhnC <br /> U TransTrenspre,1Comany No" pIr EPA,OO6 H N <br /> umtar <br /> FRFl3W 4 <br /> TrenspaearTcempanrNor" V NY ''I Mlli O 5 1 S 9 <br /> wcMt-E)WI ReGO A R p o <br /> ICand Sfte Address 79 yfgsSeG S <br /> aPMFa1111 <br /> arA.,. 12 unit <br /> 1JI1AM S7 11 Total 'Ni Nal <br /> 2730 E 13TH ST iii IO.Containers Quantity <br /> O PUMA AZ Na Type <br /> 344-9828 <br /> 0 Facilrh's Phwre' 9� 6hipPin9 Name,Hazard C1as6.10 Number, [' �'�• <br /> OOT DesrAPtinn linrludin4 l"0 q <br /> 4� MM and Packing Group IVI ' <br /> sour' .t l �l <br /> 6 4 i{ <br /> U <br /> :;?A I I <br /> rY M <br /> O <br /> U <br /> Q 0 <br /> O <br /> U <br /> 41 <br /> C <br /> bD <br /> ' 1G[T135 ER60171 <br /> U <br /> � 14.Special Handling lnsWctieos and Additional Information <br /> � 14.zN171.NRS lY]{i1' r•"ii' r1f[v`L•'.11 A! . <br /> 41 <br /> a--r the Proper er shlpprng name.old are classified,paeka9 • <br /> (6 <br /> C <br /> hA 15. GENERATOR'510FFERGR'S CERTIFICATION:I hereby declare that the contents or this consignment are fully and accurately described above by P <br /> 'an marked and ladeledlplacarded�ms of this cons are in all specttnt c'inropeform to the tterms for tf the a achedrEPA Acknow edgmenl of Conslen�national governmental regulations.if export shipment and I am the Primary <br /> 41 Exporter.I,a"Inst the conte if I am a large quard generatorl or(b)(it i am a small quanhly generator)is true. Month Qay Year <br /> -0 1 certify Brat the waste minimixafion statement idenlified in 40 GFR 2$227(al{ g <br /> 5ignAture <br /> C <br /> Gereralarsfoflerors Phnted(7yped Name <br /> Y — <br /> U ❑Expart from U$ Port entryl <br /> t6.mlemabonal Shipments ❑Import to U.5l- Date leaving U.S." <br /> IL- <br /> Z Transporter signature Ifor expods only): <br /> W 17.TranspoderAeknowledgmenl d Receipl of Materials Signature Month Day Year <br /> Transporter I Printrarryped Name <br /> M <br /> n ad. Month Day Year <br /> yTransporter 2 Printedlfyped Name Signature <br /> Lr) Q <br /> O <br /> N 1a.Discrepancy <br /> O <br /> 18a,Discrepancy Indication Space Quarldy ❑Type ❑Residue ❑Partiai Rejection Full Refection <br /> a--r <br /> N <br /> 41 <br /> '•� 1 Manifegt Reference Number, <br /> >- lab.Alternate Facility(or Generator) U.S.EPA 0 Number <br /> E <br /> 4-1 LL Facility'sPhcns: <br /> L") C1 18c.Signature o"'hoo'ate Fadlily(or Generator) Month <br /> Lu Day Yea <br /> � a <br /> z <br /> 7 19.Hazardous Wasle Report Management Method Codes(i.e.,codes for hazardous waste treatment disposal,and recycling systems) <br /> 1 2 3. 4 <br /> i <br /> N U) <br /> r6 = <br /> 26.Designated!Facility Owner or Operator Cedifralian of receipt of hazardous materials covered by the manliest except as noted P tied in Item tBa <br /> PdnfedlTyped Name Signature <br /> Month Day YF z <br /> c s_ Q <br /> EPA Form 8700-22(Rev 12-17) Previous editions are obsolete. <br /> GENERATOR'S INITIAL Cr <br /> 0O <br /> N <br /> NO O 0 <br /> r GO C4 — <br /> 04 �0 d Q <br />