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Please pool or lype,(Farm designed for d,e r1n aide(12-pilChl typeWrllen) Fnrm AYrprc'vr:d.OMB Na.2050-0039 <br /> UNIFORM HAZARGOVS 1.Gencl'utor 1❑Nunrq.r s.pope 1 3 Emergency Response Thane 4.Ma nifosl Trashing Numq.r <br /> R7 <br /> WASTE MANIFEST - SKS <br /> �V C� <br /> _G.neralo�t N:une anJ Mailing Address Generators 51le Address{if diXerenl than mailinal:xdemse) a7^ <br /> 6.xT.....ner 1 Cpmparty nanr.. U S.EPA 10 Number <br /> _Tra spa"ar 2 Company Name U.S.EPA ID NPm;wr <br /> B.oesignated F—my Name any S-tn Addrasa - <br /> _ LIS EAq Ib Nump¢r <br /> i+FElrjq Fl.i - - <br /> S1v/I-79S--+«41Bed - _- <br /> —10 1s Phone. -- <br /> lye, —U -DOT Description(lnstuding Proper Shippin9 Nam.,Hazard Glass.ID Number, 1(f[:enlalners 19.Total 12.U- <br /> HM and P.ck —­(tf any1Y No. TYP. amity WtNal. la-Liva ate Godes <br /> o E's l-PYLEN{= GtYCE1L SULCJ'i TDrkN L-Ess THAtd no-, <br /> ca <br /> 3. <br /> a. <br /> 1a.aPnrial Harwu<ry urXhuu�unS and Addmnna en rmavon f-„ E-,v Ei <br /> ]5. GENEP:ATGR'Sro>=PEROR•S cEd r.1 ATI ON:I hereby declare that nw rr.ntrnts nl rnia cvrfslgnment are sully ono accuravly dxr-n+ihed nhnvn by Ih[:proper shipping name,arra aro 4lassifietl.packaged. <br /> arkid end l�beledlplecartled,and are in ail msppul::ni iuuPur r�ndinun{or IrensI, according b applicabits nrlorrretiunal one national governmental nsgutalions_If_r—shrpmenl and I am the Primary <br /> Exlwrter.I—fy that tlm—tents of thls—.gnm.nt the terms of IM1e attached EPA Achnn.,r.dgmnnl nTGonsent. <br /> w•liN Ifiat the waste minim Vze Xon s=ai0menl idenMred in 4(1 C:!-R 252.2](a)(if I uni a luryr-yuan tity gene—')or(b)(if]am a""H yuamlty g.n.--)is true. <br /> Genera[efalOXemrs PrinlatllT•ypetl Name SignaWre nnth Day Yeer <br /> £ _ <br /> 18.tntumational Shlpmenls Impon to u5_ u Expo"from U.S. Port of entry ex1S _ _ ___ <br /> Transporter sir;neture ifpr expone PnIY): f],xrr.Irtnvrn�l U.S.' <br /> W 17-T—Ns ner Ashnowledgmenl of Recalpl of Malarial, o <br /> t` lransPnrinr 1 PrintpJlTyp.J Name G'rgnature nnlh o <br /> [fay Yca r <br /> Yranspoder 2 PrinledlTypatl Narrfe Si store <br /> � 9n MrrnrM1 �ny <br /> tr <br /> 1X.b.....Panay <br /> 16a.0iacrepancy Indication Space F—I quanSly <br /> d Type 0 Residue L-1Partial Releutipn E-1 Fntl Rereclidn <br /> Manila st R.farenca Number. <br /> lyt.,ARarna[e Facility(or Generaror) 11,5_CPA ID Number <br /> drity's Phone. <br /> t� 18d Signatu re of Allernale Facihty(or Generator) MunJr - Year <br /> 39.HazarcSods Wast.Ke ,i Managorrx.nt Method Codes(I e„codes fur hasardous waste Ireatmarrt disposal,antl racy Jing syst¢ma) <br /> 71 <br /> �O Oesignatetl FerJfIN rTvner pr OpBrator c. ca lien p(receipt of hazardous materials ravemrl qy ue maniiesl enwpl as ncleJ in Item lSa <br /> }II rinledlryped Nsma Signa r Mon h ay Qar <br /> EPA Foran 8Y90-22(Rev.3-05) Previous editions are ogsoiete. DESIGNATED FACILITY TO GENERATOR <br />