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fi - Please print ortype (Form designed for use on ehte (12-pitch) typewriter.) , I I Form Approved: OMB No. 2050.0039 <br /> UNIFORM HAZARDOUS ; 1. GeneratprlD Number • 2. Paget of 3: Emergency Response Phone 4, Manifest'T' -eking Number ' . - <br /> WASTEMANIFEST - ' U1E43yy��,e£�,- 3 . vj <br /> ��aro�,a ,? L ,f�1 P".0 i'3 "rc � DAT <br /> S:Oenemlofs Nameand MailingAddress - O " °� � Q&. A <br /> a to /llY &3 �9I I4fwa Generators SileAMIMIss llfdMerent than maLng addms;) <br /> `SI 3dww 1 a sg°S, &`'9 - _ TGA B g• .'iS& l107 - <br /> faat3'fi$ 'ems <br /> Generaloes Phone: `)' '-� � ���� <br /> � - 6. Transporter l Company Name - - U.S. EPAID Number <br /> I>4}S 36dM7C5 Eh3Q ExRim^e�ie �, Ff ' �� u`L7 3 $�✓�rvem� l9c-e y CARD�� d'�Cw'�f .. <br /> Z Tranapmar2Company Name ' - - 11.S. EPA ID Number ' <br /> 8. DesignatedF c011y�Name and SileAw.dbdre.qsg - - U.S. EPA ID Number <br /> ViEkl3�ti2�reffi5rt <br /> 5 a�4d �+ 2i4 ti�€ ��a62� <br /> Faclitys'Phone: . �' <br /> igo. 9b:U.S. DOT Description (mcludng Proper Shipping Ne, Hazard Class, ID Number, 10. Containers i1. Total 12. Unit <br /> NM and PakingG p (Ifany)) No. Type Quantity -. WWni13Waste Codes <br /> o1. F9 T RIC,FPF�1HanOwnVft, * Lsl �l?,vmnEjj) <br /> � � a <br /> � 2 Ce r R1 c S flet @ ipm mil mlya, aj) <br /> 223 <br /> If' 4. . <br /> f , <br /> 14, Spedal Handling lnstrdcgws and <br /> Addmonal lnforma ron2) 1001410M <br /> .'I <br /> �aagqn� 3.99si3 2zfl91 <br /> 7i Cartlr�E.s�trss::1 ssxcarfgy,. y3 ...fiy � , "1,2C�a-^�rsrtof? s? ,;.,� a;tT�fis� �A�-�,�:^imac, 9 ,7016ir2:a <br /> 15 GENE RATORStOFFERORS CERTIFICATION: Ihereby d darethal thecontents of this consignment are fullyand awturat <br /> sly d crib d abovebytu proper shipping nm and are lassdedp ckaged - <br /> marked'and l beled/pl arded, anda in all resprids inpopercondiaon fortmnspod accordingto applicable lematmnalandn national governmental regblahons: if expert sh pment and lam the Primary. <br /> ExporterI rtify that th contents fthl consignment conform loth? H s of the aeachad F.PAAcknowledgmet of Consent. <br /> lwrbfyfhetthawatem Imingonetotemmtiddnbhedln40CFR262:27(a) (glamalarge quanlitygsnemtor) or@) (llamas aUq Sly geneakr) is We. <br /> i ' <br /> Grenerabir'sl0fromes Pirme'd/Jyped Name - Signature 'Month Day Year <br /> 1 i 1611 tonal Shp ;rile - - _ � <br /> - - ❑ Impodio U.S. ❑ Expert into U.S. Portofenlry(edt - <br /> jllll Transporter signatures (for exports.only): :Dale lembig U.S.: <br /> �. 17. TransporlerAdenocredgimmill of Receipt ofMalemers <br /> sc, Transporter I Pdnted7Typ d Name Signature <br /> O MpkdA Day Year <br /> mfi <br /> C. T nspoder 2 Pen1ed7Typetl Name <br /> f, / �! t 8lgnlal�� � Monlli Day Year <br /> lrr lli7 A 1 Z of Ll 4 �s. -✓" <br /> 18 Disenegamyr - dv`���` � - .. . .��" ( <br /> ,/� - <br /> _ <br /> 18 Dscrefel indication Space ❑ quantity ❑Typo _ - rl <br /> ❑ R Residue ❑ P rb Ift jechon ❑ Full Rejection <br /> Manifestimlerence Number. <br /> 181bAlmiate.Facilry( rGenemlof) <br /> U.S. EPA ID Number - <br /> w Faclfitys Phone: <br /> a18c Signalum ofAlle _ate Facility (or Generator) - Month Day Year <br /> z <br /> w19. Hazardous:WasteReport Management Method Codes (i.e., wiles for hazardous waste beaM_ nk disposal, and recycling systems) 41 <br /> , it <br /> 20, Designated F.Namac <br /> Pnnied/(yped plty 0`vmn�Dpeml r, CeNfiwtlonpfrceipto/hPaardous marshals coveredby the manAeslaremplasirdedin Item Ise - " - <br /> e - (J ' '1� Signaturg l ' ' Month _Day Year <br /> EPAFrgm8700-22 (Rev. -Q5) Pmvious, entlibinsamodeauMtv, It G� <br /> KSIGNATED. FACILITY TO' GEPfERAT& <br /> I <br />