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FROM : L.F.W. MFG. INC. FRX NO. : 209 465 6521 Mar. 09 2007 08:38RM P6 <br />Please print or type. (Form designed for use on elite (12 -pitch) typewriter,) Form Approved. OMB No. 20.5( <br />UNIFORM HAZARDOt1S 1. C�nerator ID Number Page: 1 of 3. Emergency Response Phone 4, Manifest <br />WASTE MANIFEST I � 01533 f'��' of 0 0 <br />5. Generator's Name an11 <br />d Mailing Address ( �� r Generator's Site Address (if different than mailing addre <br />�td�s Phpne: 4r/®�_��� <br />Facility's Phone: �pn <br />U.S. DOT Description (including Proper Shipping Name, Hazard Class, ID Number, <br />HM and Packing Group (if any)) <br />10, Containers 11. Total 12. Unit <br />No. Type Quantity WtNol. 13. Waste Codes <br />M-Ma2m MMM—Floo <br />C+ENERATOR'SWFEROR'S CERTIFICATION: t hereby declare that the contents of this consignment are fully and accurately described above by the proper shipping name, and rico classified, packaged, <br />marked and labeledlplecarded, and are in all respects In proper condition for transport according to applicable international and national governmental regulations. If export shipment and I am the Primary <br />Exporter, l certify that the.contents of this consignment conform to the terms of the attached EPAAcknowledgment of Consent. <br />I cetttfy that the waste minimization statement identified in 40 CFR 26:2.27(a) (K t am a large quantity generator) or (b) (if I ern &smeil quantfN cienerotorl is true. <br />LJ import to U.S. <br />Ttarrspfxtgr xignature (for exports only)! <br />17. Trattgportar AckridaNgment of Receipt or Materials <br />18. Discrepancy <br />18a. Discrepancy Indication Space❑ I�i Quantity t....1 Type <br />180t4.mate Facility (or Generator) <br />Facility's Phone: <br />� 1t3a $kytatur� ofAltemale Facility (or C,enerato� <br />z <br />G7 <br />Export from U.S. Port of entry/exit: <br />Date leaving U.S.; <br />❑ Residue ❑ Partial Rejectldn <br />W19. yazardous Waste Report Management Method Codes (im., codes for hazardous waste treatment, disposal, and recycling sy$te=) <br />20. Designated Facility Owner or Operator Cettiftoation of mcsipt of hszardauc materials covered by the manifnct —Opt as rx44d In Itam 182 <br />tinted1Typ me <br />:PA Form 8700-22 (Rev. 3-05) Previous Editions are <br />Year <br />Gr . <br />❑ Fug Rejection <br />DESIGNATED FACJLFT'( TO DESTINATION STATE (1F REQUIRED) <br />