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Please print or type Farm Approved OMB No 2V4M0 i. <br /> UNIFORM HAZARDOUS 1 '�!7' ID Number 2 Page 1 of 3 Emergency Response Picone 4.Manifest Tracking Number <br /> WASTE MANIFEST � :: �' K n ; ' 4 JJ K <br /> 5.Generates Name and Mal Erg Address Gereralors VII Address(if drlferent than rr Ong address) <br /> GeneraW3 Phone. <br /> 6.Twsponer t Company Name U S EPA tO NJfunber <br /> 7.Transporter 2 Company Name US.EPA 10 Nrmber <br /> 6,Designated Facility Name and Site Address U S.EPA ID Number <br /> Fermi s Phone: <br /> ga. 9b.U.S DOT Description(including Proper Slipping Name Hazard Clan,ID Number. 10 Containers 11.Total 12 Unit 13,Waste Codes <br /> HM and Pacldng Grafi(If any)) No Type Quantity WI.Arbt. <br /> t ` <br /> 2 <br /> c�7 <br /> 3 <br /> 4. <br /> 14.special Handfirg Imtnrctals and Additonal Iraom,ation <br /> E.!i. OfJt'iFa�.GT13r• ft•rf.lC� Ei, 9r{r,};.ih1�t)' >, <br /> bi�1 tFF:i.SIA ALU ;:t4S <br /> 15, GENERATOR'6fOFFEROR'S CERTIFICATION:f hereby declare that the conlents of grin Consignment are fully and accurately described above by the proper d4v name,and we classified,packaged <br /> manned avid la6eledfp3ar'arded.and are in al respect;In proper condi m lar transport according fo applicable irrtematahalmhd national gowmmeotal regulal om n export shipment and 1 am the Primary <br /> Exporter,;cer 041 the'wntents of fib c ihsigrrnenl conform to the terms of the ateched EPAArJo> Wedgrwl of Consent. <br /> I cerbfythat the waste rtdnmt atlDn statement identfled In 40 CFR 262.27(x)(d I am a large quantdy gerneratnr)q(b)(di am a small gentry generator)is true. <br /> Generaloes1OReroes Prinlmayped Name.f Sigrhahae Moots Day Year <br /> .., 16.International Shipments <br /> ❑Import to U S. ❑Export from VA Pat of emylexit <br /> Transporter signahn(far exports ally): Dare leaving U.S <br /> 17,TronSporterAonowledgmentof RecaMaf MaWri*3 <br /> hr Transporter I PrIntedlTypad Name:` i ! $ignatia Month Day Year <br /> ; r <br /> Transporter2printewypedUarne svn=e Month Day Year <br /> 16.Dismepancy <br /> 16a.Disaepancy Indication Space ❑ Quan;ty ❑Type ❑Residue ❑Partial R*d. ❑Fut Rejection <br /> Maaitest Reference Number: <br /> I$b.Alternate FacIly(or Generator) U.S.EPA ID Number <br /> LL Facilllys Phone: <br /> t6c Signature of Alternate Fadity(or Generates) MonM Dr! Year <br /> 19.Hazardm Wasla Report Managemeril Method Codes(i e.,codes for hazardous waste treatment,disposal,and rK)%J rg systms) <br /> cn <br /> LU 0 1, 2. 3 a <br /> i-! 1Lsl <br /> 20.Designated[Facl4ly Owner or Operator.Cedfication of receipt of hazardous mdmiab covered by the manifest except as noted in Item 182 <br /> PrintecVTyped Nss^me Signature Month Day Year <br /> EPA Form 87W22(Ravi 12-17) Previous editions are obsofele. <br /> IF YOU RECEIVED THIS MANIFFST,YOU HAVE RES PONS I9A.tT FS N <br />