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Please print or type. (Form designed for use cn-elite 1,112 -pit <br />UNIFORM HAZARDOUS Generator Number <br />WASTE MANIFEST <br />Generator's Phone: <br />0■WAB 77 <br />0 <br />B. Designate: Facility Nare and SiltaAcicrass <br />!S <br />Facility's Phoie: <br />Sb. J.S. DOT DescT.jtion tine ud:rg Proper Shipping Name, Hazard class, ID Ntxnbet. <br />H Iq End Paciiing Group fif ary)) <br />J i.'E! L: <br />0 <br />ME <br />. '4--U.S. EPA 10 <br />Form Approved, OMB No. 2050-0039 <br />mg Number <br />r%.1 4: SKS"' <br />10. Contairers ,1. Total 12. Unit 13. Waste Codes <br />No. _1�pe ajanity Ohm,. <br />ndling-!rstwons and Additional Information <br />k. <br />f `9ri MIEF <br />El ' " '. --, V <br />• u; <br />A,- 1� 'j <br />I . 5. GENERATOR'SIOFFEROR'SCFRTIFICATION: I hereby declare that te ocnierris of this co-isignmeit are fully and accurately described Z;,e by :he proffer shipp.ng name, and Ers c2ssilied, mckagW, <br />g to applicable internationaland national governmemal regulations. If export shipinertand lam the PrillarY <br />rrae�ed and lsabeWpiacarced, and are in al respects in proper con-'ition for transport according <br />Exporter, Ice* tot the c4nterds of this ccisignment oonform to the terms ofttvy attached EPAAcknoA*dgmentof Consent quant tj g eneratce is we. <br />mizaJon statement identlied in 40 CFR 262.27(a) (H I arja large quantity generator) or (h) iff I am a smallI certk.� that the wade rnini Signature Mon5i pay . , yea - r <br />Generator's;0iferoes PrintecIrryped Naris <br />_j 16. IntemaJonal Shipment --Ere.? Oto U.S. ❑ Export from U.S. Port of entrA%xit: <br />El -P.- Cate leaving U.S.-. <br />Transporter signature4fbr expers prily) <br />w 17. TranspoTterAckrv.-Aedgment of Receipt of IABterials Year <br />Sigrsture Dav <br />Name <br />Tiansperter I Pdnted)T <br />0 it <br />CW Year <br />Tmrsporter2PrintecVjyOe4t�Te...- SignatuMontl� Day re, <br />Ile. Discrepancy Patil Rejection ❑ Full Rje=ion <br />lea. Discrepancy Irdication Wce E]Ouanik ❑ Type ❑ Residue ❑ <br />Manilest Reference Number U S. EPA VD Number <br />185. Alternate FaLlity:or Ganerato(i <br />Nioith y Yea., <br />Facility's Phone: <br />18c. Signature of Allemate Facility (or enamtor) <br />UJI <br />I Hazardous Waste Report ManageTren. Method Codes (i.e.. codes for hazard --us waste treatment. disposal, and recyc'Ing systems) <br />111111111 - 7 <br />us1. 2. <br />20. CoEsignatEd Facility Owner of 0aerstor. Certification of -eccipt of hazardous materials covered by the ma-iiiest except as noted in Item 18a <br />Prinlecilrypec Name Signatre ......... . . . .. . . EiDnt . h Cay Year <br />EPA:For�a.-87022 (R0. 3-05) Previous edjt;bns are obsolete. GENERATOR'S INITIAL COPY <br />V'd 699L -99t -60Z siqueelo MOUS ett:OI, 06 60 qef� <br />