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Please Print or type.(Form designed far.use Dn elite(12-p1tch)typewriter) Form Approved.OMB No.2t}5t}-0((139 <br /> [55. <br /> IFORhI HAZARDOUS 1 Generator fo Number 2 Page 7 of 3 Emergency Response phone 4.Mani�ast 7rackln M¢WASTE MANIFEST Q L` �+ -renerators Name and Ma bg Address V v �+A K.` Generators Site Address: ddierent than ma.!;ng address)P Ci ,',:—OC 'A' Phone: <br /> er Mompany Name U.S.EPA 10 Number <br /> V Lir tflL"r2 Company NameU.S,EPAID Number <br /> d Fat ' Name rf[`��1Fi T*? J �H IG - U.S.EPA 10 Nutter <br /> i;;4-1 E S'7.Z94Af>R r$".. <br /> 63ttrri:°1E-�.C <br /> Fadhtys Phone: ; XM <br /> Flb�,U Deiaiption(nduding Proper Shipping Name,Hazard Class,t0 Number, 10.Containers.Group(Many)) 11.Total 12 Unit13.Waste Codes <br /> Quantity WtNOI.:,l"V=: <br /> z 2. <br /> 3. <br /> i <br /> a. <br /> . t <br /> k WSpm>cial FEandEng instructions and Additional InfortnabM � 1 <br /> 15. GENERATOR'SfoFFEROR'S Ctmj lt.ICATION: I hereby dedare that the contents of Ibis consignment are fully and <br /> marked and labeledlplar�rded,and are in all aowre*described shove by the proper shipping name,and are dans w'pacfmgetE <br /> �n Pyr condition far transport a=rdfng to applicable tntemationat and naBWW governmental regulations.if export shipment and 1 am the Pr4n <br /> EuPotter;'t eettity that the contents of this oonskjnment conform to the terms Of the attadted EPAAclmowledgment of Consent. <br /> 1 certify that the waste minlmizatlan statement Uenti6ed In Q CFR 28227(a)(M I am a large quantity generator}or <br /> GeneramrsrLMrors PAntedfr (b)(ifI am a smaq 9 MY tlenerator)h true. _ <br /> yped Name Sg7atura IJonth lay Year <br /> � <br /> 1d.Intematlonal9lmipments T <br /> j O 1 <br /> z Transporter signature{for exports onl❑Import to U.S. ❑lxport from U.S. Prat of eentryleAt; <br /> rk Date leaving U.S_ <br /> LU <br /> 17.TransportarAdmowledgment of Raceipt or Materials <br /> Tratms,�orierlP n 'lppRe are _ <br /> f/ 5ignattae f J Month Year <br /> caf <br /> a raruparter?Printerfliyped Name P' !-� � � <br /> Signature Month Day Year <br /> 1 B.Discrepancy <br /> 18a,Discrepancy Indra&an Space <br /> ❑ Ouantty ❑Type ❑Residua ❑Partial Rejection <br /> ❑Fun Rejedion <br /> 18b.Altera a Fadliry(ar Genera9or) Manliest Reference Number. <br /> U.S EPA W Number <br /> U <br /> L Facility`s Phone: <br /> LOU 18c.Signature of Alternate Facility(or Generator) <br /> i Month Day Year <br /> LU 1 Htu rdou�Waspf R9pat Management Method Codes(i.e.,codes for hazardous waste treatment disposal and recycling systems) <br /> 2. <br /> 20.Designated FaaTrty Owner or Operatot,ZeMcaEaryvf receipt of hazardous materials covered by the manifest except as nded in•ttem i as <br /> rinta� ypdd N!I f <br /> d � f Signature —� <br /> ' ? rNonth ay Year <br /> EPA Farm 87©t1-22(Rev 3.05) Previous editions are obsolete. _ <br /> TRANSPORTER'S COPY <br />