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,O <br /> .... ..... . .. <br /> 3 <br /> r <br /> or <br /> me <br /> Please piit}I at ; l trt'fr tfor use on elite ('(;K;pttcfi)'t bvrrttet: " z Farm: .;' :; OMB No, 2t)50 0039 <br /> 1 Generator ID Number 2 Page i o mergency esporrse one an esti[@4 num Ar <br /> UNIFORMH RDQUB ' L: I <br /> 0 T <br /> WASTE M IFE9T <br /> :.;.. .9 .: . .. <br /> am At 0 <br /> 7 JJK <br /> different than mailing address) <br /> tt ' <br /> ... d. i": : l ik <br /> LOW <br /> a <br /> QanerttttltR IiDaC. . <br /> 11: Transpoi _. d . <br /> . . . .. _. .. ::. r I.r <br /> M4 me <br /> :-: <br /> 7; Trarispctter 2 Company Name w u <br /> ._ .. . ...... . . ... Im <br /> s d cIf earid S't dre U.S. EPAIDNurnber <br /> s s ` .. <br /> AR A <br /> I <br /> 1?. sPhone <br /> i � ` . <br /> 84 . <br /> . . . . .. .. . n ;. , m 4 m. I 1 9 r - <br /> ga 9U> U.S DOT Description (Including Proper Sh(ppfr� Name Hazard Class ID Numhar O.:Contalaers 11 total 12rUnit "" . ''.13. Waste Codes <br /> Hof ; and Pac��kiing Group (if any)} No: Type Quantity WtJVo1x <br /> Q � � > nx <br /> w: { <br /> Y <br /> br <br /> .. .9 m . .. . .. .. . . <br /> 3 LL <br /> 91 mI ZO <br /> <- <br /> _ _ . <br /> _ . <br /> g. ::. <. <br /> k; } <br /> IVm <br /> mmw <br /> 14 Special I are Ingins and Additiana! l fprmatan <br /> mw Vm+ <br /> I " gip. . . <br /> _. m _ ..._.. ._. I. <br /> , . . ...:. <br /> to : GENERATOR'Slt7FEEROR`S CERTIFICATION. , hereby declare that the contents of this consignment are fully and accurately described above by the proper shipping name, and are classified, packaged <br /> marked and labeied'piacarded, and are in all respecf�s in proper condition for transport according in applicable international and naElional governmental regulations;.if export shipment and I am the Primary <br /> Exporter, : certify chat the contents of this consignment conform to the terms of the attached EPAAcknoMedgment of Consent,. <br /> } tfly:tFaI the,waste Mintmiza8an statement iden9fied in 40 CFR 6 J{jJ QfF1 am a la ye dttrkitjiy generator) or JR i[I An a smallquantily generator) is true., <br /> >, . <br /> Qererators!OPeror s` ri itedlTyped Name - Dai <br /> � �3 ; <br /> International Shipments. <br /> Import to U,S� 1 Export from U.S. Port of entry/exit: <br /> m me <br /> Transporter signature (tor exppits onty); Dale leaving U,S <br /> tT TransporterA itrm viedgttrent of f2eceipt of Materfs <br /> Trrt rt. tsdtfypt�tfineA Signature ti9bft . pig <br /> rn <br /> it tit ► ' .: I <br /> z, en. ` "2�nnt ame <br /> a ; <br /> : .. ..,._ _ . . . _ . _ ...._.. <br /> 98- Discrepancy <br /> 18a. Discrepancy Indication Space <br /> ❑ e <br /> Quantity Type Residue ❑ Partial Rejection Full Rejection <br /> _. . .._ . _ .__ . :._ _ . .. . . ......... . . . . -. : daaifas Reterensar. tnber. <br /> 18b, Alienate f acilify (o Generator) _ U.S. EPA ID Number <br /> a <br /> raclity's {'hcne: <br /> ` 8 aigtiafur a o i atnataFa ` a or Gcti7e at6r} _ _ ...... Month.... Day... . ear <br /> a <br /> z <br /> 19. Hazardous ste Report Managernoat Mettrad Codes {fid :codes atdtreatmerf,.dlspeI- an <br /> Wafaatta vraste d ipcytU... sysEtkxk+) <br /> rUjr <br /> s <br /> 2' .. <br /> s <br /> 2d. Dasitina`ed Facilry Or,ner or Operatar. Certification of receipt of hazardous materials covered by the meniiesE except as noted in item 18a 1 9 19 144R j <br /> Sid., <br /> n} tt ay eaature na om � ftn <br /> r k F i.t 'fir F 3 < £ME <br /> S, r <br /> . . . ... <br /> E 'A Fgrm 8700.22 (Rev,, 3-OG) Previous editions are obsolete, TRANSPORTERS ERS COP) «1 <br />