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C— -0 CY) <br /> D Zy- N cn <br /> Cl)O �'�Y w�i,re~ - rt - Ul <br /> O <br /> z ' 0 o m <br /> D r:Nrr•O Z7 (D <br /> D WAS 7 �E M/lr4fFEg� — <br /> a <br /> z s>a ,Nam_n..'_a a_m. .- AWess:fyn 1� 7 oS <br /> SK O <br /> a , , ou <br /> 2 R , .. v <br /> O <br /> 0 <br /> C � <br /> V.S.EPA10 Numpe. O <br /> 1 a Desyna�d Fa„ <br /> VS EPA VUNymb.r 3 <br /> ({�miieil.i- --- n-v lL�S. Ifs U.S.EPA ID NII fy <br /> Facd;ry'S Phnne.- Y c N <br /> 9b.VS eh,_ _.._��Pr—Shi S2 <br /> FrM and PellPpinC Name.Ha=art ryas.iD NImM, :'�QI O <br /> r,ypyr_, }[.Cooraners It Total 12.vn't CLn•-``��--^^(���L�� No. Type �e�an:�p; �;'1.: 13 YYaSre Cppe� G <br /> aEli <br /> - ;.4 3 rN <br /> tz -F <br /> [7 fD <br /> 3 <br /> N <br /> I'D <br /> rn <br /> rF <br /> O <br /> O <br /> V <br /> It- <br /> Ul <br /> 14.Spedal Nandfirg IT Insfiur;bions and RddiGonal Inror..... � <br /> TSD;K= N <br /> 331dri. <br /> C/r <br /> 124H �R6ENCY*SM-4t=,"— 760—CFf/gK/TFI—Contract retained h � <br /> nn nitia2 t errs r er o ecf o Y generator Grf. cn <br /> 7' GENER0 T 'SlOFFEROI CERTIFICATION: I hereby declare that the cements of this co sigJr <br /> nmeM are fully and accurately described abovE b me ro <br /> por marked and IabelediDlacarded,and are in all respects in proper condition for Irenspod according tEli <br /> o appiiwb€e international and national governmental regulations.�lpeapen ing =r:�.pment and I am me Primary rn <br /> Exporter.l cel III the contents of this consignment conform to the terms of the attached EPAAchnowledgment of Consent. O <br /> f certify that the waste marlimizalion statement identified in 40 CFR 262.27la)(if I am a large quantity generator)or)b)[if i am a small quantity,generator}is true, <br /> GeneratorstOfterl Printedrryped Name Signalure rEF <br /> 16.Interriational Shipments rEF <br /> ❑Import to U.S. ❑Export from U S Port of enlryleail. <br /> Transporter signature(tor exports only): <br /> Date leaving U.S Irr <br /> 17.7ransporterAcknow"ment of Receipt of Materials <br /> L OS <br /> Transporter 1 Pr nledlryped Name Signa[u e Month Day vtar rt <br /> Eli <br /> 7ransporter2PrntedffypedName NiAure Month Div '1e3: • <br /> rD <br /> B,Discrepancy Q- <br /> Q <br /> 9a.Discrepancy Indicator Space <br /> Quan?dy ❑Type ❑Residue ❑Partial Rejection FuB Re;ectlon N <br /> El <br /> Uq <br /> Manifest Reference Number <br /> r+ <br /> Alternate FKft(or Generator) U S EPA ID Number Q <br /> C <br /> v <br /> ility's Pirofle: 0 'G <br /> Signature ol a AJIlial Facility{or Generator} P.Ycnlh Da, a o (u <br /> rQ c) <br /> � O <br /> sv Q <br /> iazardous Waste Report Management Method Codes(e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> 2 3. 4 2 <br /> O <br /> v signaled Facility Owner ar Operator:Certi6Cation of receipt of hazardous materials covered by the manifest except as nded in Item 18a 1 ear Ul <br /> Month Qay 1 <br /> c0 Signature Cl) <br /> m Ryped Name 00 <br /> O <br /> O GENERATOR'S INITIAL COPY <br /> 700-22 R v.12-17 P vious editions are obsolete <br /> 35484. <br />