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m o * D 3 * < � a� � <br /> v COL) 0 N v p = �' v <br /> D 3 - 0 � vvO �cQ <br /> D C a w <br /> v eco CD 5. 0 Oo � <br /> 0 CD m o ccn <br /> cn <br /> CD .. 0 � <br /> Q o 00 <br /> Q vM v N <br /> O <br /> - l (D CD 00 <br /> (D .� CD CD CD <br /> TI IIII� CD <br /> -0 L L <br /> CD C (Q C 3 Ln <br /> W "i'm ow No cDD .--r 3 n CD <br /> Please print or Npe. 2 Page a Eme Phrme 4 Wee•st TrscHrrp CD O <br /> UNIFORM HAZARDOUS ""1Pralor lD Number �°n�' p0^� I = C _ <br /> WASTE MANIFEST " . '- ` FLE � N <br /> EGeneramr's Name and rt+.em,.;aa,tr.+.ts > Generamrs ane Addreee(M dlRermtthaa ling eeunsrO Q O CD n Q Q <br /> CD Q" j O 7 <br /> O <br /> XO a) <br /> Goessaterl Phone. E I N;m!t �_ (D C••). <br /> o T2r+sporler t cempanY Nan,r <br /> rrt -LIU, (D i Q Q <br /> ?T,ansrwrter 2 Company Nama a 5.EPA ID Number �' <br /> .�+ CD O <br /> R Ci s-unaled F—Hy Nam=and Site Address U.S.EPA ID Number <br /> o � Q � � <br /> 5 CD Q O <br /> CD Cn C 7 CD ? <br /> Fau'rty'=Phooe 0 0 .C-r(Il N <br /> 9b U.S.DOT Dascnol- er Shi In Name.Hazard Clan.ID Number 56.Containers O r••" D <br /> 9a. Ni9 p PP 9 ti.Total O O_ S <br /> HM and Packing GmuP fif any]) No. Type Quantity 13 Jule Colds Q 0) O <br /> LD. S. o 0 <br /> o N �_ <br /> N 0 <br /> 2 <br /> Q <br /> l/ F <br /> CD O O <br /> - � �d C <br /> CL (D ZT cQ <br /> C s CD ZY <br /> CD <br /> a Q' (Q 0 N <br /> v <br /> Q 7 ON <br /> CD a CD CD O <br /> 14 Special Handling!nsTudons an omb Cn <br /> v <br /> O N 0- CD <br /> 15, GENERATOR'SIOFFEROR'S CERTIFICATION:I hereby declare that the contents of this coni nment are full and accurate! described above b the proper shipping j <br /> 9 Y Y y g p ppmg name.and are classified,111, ed. <br /> marked and labeled%placarded,and are'm all respects in proper condition for transportaccording to appli c: one an na ia9'idlyovaQimental regulations.If export shipment and am me Pnrtary CQ 0 <br /> Expodec ceNry that the contents of this consignment conform to the Eerms of the attached EPA wledgment of Consent. .� <br /> that the waste minimization statement identified a 40 CFR 26227(a)(if I am a large qua ty generator)or(b)('dl am a small AgYt`g neratorf is true. <br /> G Iors10 roes Prin jJyped Name <br /> ,x re ,^ ._�:rnM Dav Year � (� �• C <br /> i <br /> 1 .Inlemabonal Shipmenls ❑ �+ Q 7 Q Import to U.S. LJExport from U.S,' Port of entrylexh C r--F CD <br /> Transporter signature(for exports only) – --- - - 6 <br /> Od ;'D to leaO U.S.: CD - <br /> 17 Transpor�r Acknowledgment of Receipt of Materials _ 3 C <br /> Transporter 1 Pnnied yped Name fn e <br /> O_ 5'nature ',tenth Dav xear N v 7. <br /> OIL <br /> Transporter 2 PantedTyped Name Signature Q C <br /> Dav hear O _ C <br /> tom. <br /> 1E.Discrepancy Cl) O X <br /> ❑ <br /> 18a Discrepancy Ir!diwtron Space G �; = 0 <br /> Dcanbly <br /> ❑Type ❑Residue ❑penial Rejection ❑FullRe]ettron 5 Q <br /> (D <br /> 1nb.Alternate Facility for Gerreratoq Manifest Reference Number � Q <br /> U.S.EPA ID Number CD _ O <br /> Faulily's Phone. C 7 C <br /> 1&SignaWre olAlt le FalaLly{or Generalarl (�D Q" <br /> O n7 C C n <br /> M14onth —Y Year '� N O ((D D Q O <br /> ig Hazardous Wste aReportManagement Method Codes(I e, 14 codes for hazardous waste treatment,disposal,arttl recycling systems) j <br /> CD N (D Q <br /> IT t 3 C7 = <br /> ' _ { 4 <br /> �il.11 0 v � N � <br /> 20 Designated Facility Owner or Operator Cerci, 'On of receipt of hazardous mateuals covered by the manifest except as noted in Item 18a (D v <br /> Frinlea!Typed Name 07 N CYI <br /> O O <br /> SignatureCD <br /> Month L1ay fear CD N C CJl <br /> cQ ;orm 870012[I Rev,12 f 7)Previous edllicns are obsolete. N 0 -a C (r <br /> CD CD <br /> O <br /> T DESIGNATED FACILITY TO GENERATO � o � � <br /> p �' <br /> 70531 C CZ <br /> w CD O CD <br /> w —,, <br />