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s w _ <br /> • r ' <br /> Prase print or1e.(Form designed for use on efts(12-pitch)typewriter.) <br /> FarmApprcvec OMB h;rm_, ,p. pg <br /> UNIFORM HAZARDOUS t•Generator iD Number 2 Page 1 of 3.Emergency Response Phone 4,Manifest Tracking Number <br /> WASTE MANIFEST / �''� z pq, -7a,. D 14 7 JJ K <br /> 5.Generators Name and Mai&ng Address Generator's Slfe Address(d diife2nt than mafifng address <br /> 1Ko <br /> a MIZ , <br /> Generat <br /> s11� , ' 9s �{ lCr <br /> 1Y� <br /> 6.Transporter 1 Company Name U.S.EPA ID Number <br /> Geufa W -t:&Ty.i.H <br /> 7.Transporter 2 Company Name <br /> U.S.EPA ID Number <br /> t3.De�nra�ted R�Y�eand��teArk7kfress:-_ - <br /> U.S.EPA ID Number <br /> 1520 E EtRUt-I7AGE <br /> Facm S Phone: �✓�= <br /> 9a. 9b•U-S.DOT Desrripbon(mdudhng Proper Supping Name,Hazard{lass,ID Number, <br /> and Packing ng Group cany}} <br /> t0.Containers <br /> 11.Totai 12.Unit 13 Waste Codes <br /> 1 Wa <br /> No Type Quantity WI. <br /> ed <br /> Pyr-s F{szSs�C1!s r � LJe M1 <br /> a V)6 <br /> LU <br /> 3. 1� <br /> f <br /> 4 I+ <br /> f <br /> 14.SpeeW Handling tnstructlons and Additional inPwmation / f� <br /> EP73#1r1 ' l Gy V0 <br /> 15: GENEttATOR'SIOFFEROR'S CERnFICATiON: I hereby cedars Thal yrs contents of this consignment are fully and aaxnate described above the r 1 !e U, f T7 <br /> marked and fabeiedlplacarded,mid am In a9 respects in Proper oandiLon far transPorl accordingdo a y by Proper shipping name,and are dassifird,packaged: <br /> Exporter,l cerpfy that the roritents of this ppiirable international and national governmental regufaf*ns.H export shipment and I am the Primary <br /> conform to the tema of the attached EPAgdmowdedgment of Consent. <br /> I Certify that the waste n1hi nization statement Identified in 40 CFR 262.27(a)(it am a large quantity generator)or(b (f I am a <br /> Generators/ Prin Name vw� generator)is true <br /> Sena / 1 anth Day Year <br /> -J 16.International Shipments,/ ❑ <br /> 14 <br /> to U.S fI <br /> Transporter signature{for exports only): ❑Export from U.S. fxt <br /> 17.TransporterAdmowtedgknent of Receipt of Materials E le S <br /> 0 TransporteM P4nte�dl�Typed Name <br /> $gnaturei Mon03 <br /> th Day Year <br /> ransporter 2 Prin;eC, yped Name <br /> Sigri- <br /> M Day Year <br /> itt,Discrepancy <br /> 16a. <br /> Discrepancy Indication Space <br /> ❑ Quantify ❑Type ❑Residue <br /> ❑Partial Relechar ❑Fuy RejecLxn <br /> 1 Bp,A temata facility(or Generator} Manifest Reference Number <br /> t� <br /> U S EPA iD Num-e, <br /> ii FaahtYs Phone <br /> W1 sac 5ignamre or Attemate Facility(or neva or) <br /> z Month Day Year <br /> CD 19ris .Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment disposal:and <br /> C t. 2 reryding systems) <br /> —11 3 _ 4. <br /> 20.Designated Faclity Droner or Operator:Cert ,50n of rek:eipt of hazardous materials covered by ftmanifeseut <br /> 11nmecamed N ame Cept as ratted in Item 19a <br /> A_A Signature Year <br /> £PA Farm 0f VU-22(Rev.3-Ub) Previous editions are obsolete` <br /> _ f/ TRANSPORTER'S COPY <br />