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Please print or type.(Form designed far use on elite(12-pitch)typewriter.) <br /> UNIFORM RMRD06S 1•General,,ID Number 2.Pae 1 of 3. mea Farm Approved.OMB No.2050 0039 <br /> /� 9 r9 ncY esptxtsa Phone 4,Manifest Tracking Number <br /> EWASTE MAIVIF!_5� I �� � �? �� _ t `7 �� l� fl 1 id 83436 JJ K - <br /> u�enegzrsd Maitin AddressGefflsralors Site Address(rf different than mating address) <br /> Transporter�Company,Name � yr .. <br /> U.S EPAIDNumber <br /> 7.Transporter 2 Company Name <br /> U.SF EPA iD Number <br /> B.Designated Fad�Named.Si°ta gddress G+e��.,ro, <br /> U.S.EPA ID Number <br /> 1�v E.- �ttfll'fl�:rtrE!.f; �-�E.ifJ►r'�"��"c. <br /> roc <br /> FacHi. sPhone' t5j1�M-FBi5-� = + <br /> ga. 9b.U.S.DOT Desrrip6,n(including Proper Shipping Nana,NaiaM pass,ID Number, r <br /> UM and Pacidnq Group(if any)) -.uY i O,Containers 11 Total 12.Unit <br /> 13.Waste Codas <br /> No Type Quantrty WWoi. <br /> � 1t�lr1P:,!<�`r��'�1a-i i?t1:r�tr�Ytr4����1':�•'+��!I?ir!�� =_il; <br /> Mf <br /> LLI _ <br /> 3. <br /> 4 <br /> 14.Spedal Handt€ng InswxXons and Addiftm intarm a" <br /> !r?c* 1'4 <br /> 15. GENERATOR'S10FFEROWS CERTfFICATIDN: I hereby declare the nts of ti�w� I ' I ~6T <br /> I <br /> marked and(abet in consignment are fully and accurately described above try the proper shipping name.and are dass€lied,packaged, <br /> edlplacarded,and are in aH proper condition for hmport according to apprxcabie intemational and eaHonal <br /> Exporter,I certify that the conterrts of this consignment conform t,the temu of the attached EPAAcknawledgmenl of Consent <br /> governmental�'latb s-If export shipment and I am the Primary <br /> certify that the waste minimization staterrx nt the <br /> in 40 CFR 262.7c7(a)(if I am a large quantity generetw <br /> for ftt�yped N S�)Qr�)(d,am a small quantity generator)Is true. <br /> Month Day Year <br /> h,T <br /> --r 16.lntemaSonal Shipments - <br /> ❑Import to U.S. ❑Export from Part of entrylexitTransporter signature(for exports ony}: <br /> 17.Tra Date leaving U.S.: <br /> rtsparterAdmoxdeslgrtrent of Receipt of Materials <br /> Tres-rcrter 1 Prirttsdliyped Name — r <br /> Srgmd Month Day IMonth <br /> 7Insp,Rer2 PrintedlTyped NDay Y <br /> 1e.Discrepancy <br /> Ila.Discrepancy'nd'cation Space <br /> ❑ Ouantty [ Type ❑Residue <br /> Partial Rejection ❑Ful Retec&on <br /> 18b.Altemata Facility(or Generator) Manifest Reference Number. <br /> "' U.S EPA'D Number <br /> U <br /> liLBE <br /> Phone: <br /> LU nature ofA;RftemateftMonth Day Year <br /> Hrdous Waeport Management Method Codes fi.e.,codes for hazardous waste treatment,disposal and n <br /> UJ 1 r r 2 recycling g systems <br /> 20 Designated Facility Owner or Operator.Certification of receipt of hazardous materials covered by the manifest except as noted in liem 18a <br /> PrtntednTypedName ,� <br /> Signature rl,"-I Month Day Year <br /> EFA Farm 8700-22 t Rev.3-05) Previous editions are obsolete. <br /> y F _ TRANSPORTER'S COPY <br />