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L Go -0 O) — <br /> D 787 s N cn <br /> OCI) Ruse prtnr or type IForm desgrexd efreraeo.l n Nhia itz.ru,:rr t i'u ter.'' Famn ApPhved C=I.tB N".1950-m'sy prt c <br /> UNIFRRM HAZARDOUS rra. f i [u,rrgsn�r Real--t'Ph— L NenIMl7raclJ Num lV <br /> Z WASTE MANIFEST 0 m <br /> s em,.r tIri 4It.z; t rf.� 06 342 SK5 N <br /> e-V, 51le AM—NdNbienla,an—ftQaddmes) 0 V <br /> to <br /> D <br /> _ sv <br /> Z VS,EPA 10 Number <br /> IT o 0 <br /> _ V 5.EPA 19 Number <br /> ll2n ROPfhlt-"NTAL �Vt. INC. D <br /> v' 9 r,esyr,an�.�-. � ..;�� V.S.EPP 10 ryumher <br /> C.iEAlyllfIRE:Jk'.: 'Jr Eo 04 <br /> FVJT Tr1ryIdI JSd <br /> �xirm �.'lyL i 7 <br /> 9a - A-rra Fmper Ships-,Name Hazard rlass.to Numn=_r lO Gontmnerz tt.7�,at It._Inn r�,Ylaste tarries 0 <br /> HA! <br /> rye, Type �uanhty cc YJI ro 3 <br /> 0 <br /> o _ S <br /> C.itf W 5 N <br /> A1L! 0 <br /> :4LJ to <br /> SILL <br /> Ln <br /> 4 IL <br /> rD <br /> 3 <br /> ILE !y <br /> 14.Sl Randl,ng lnstructians and Additional Information <br /> 7 <br /> _ (U <br /> rn <br /> f-r <br /> ...-..., ackaged, S <br /> GENERATOR'SIOFFEROR'S CEATIFICAT10i I hereby declare that the contents-of iliis[con5ignment are fu ly and`accurately e'Scnhed ahov'by-�ne'pf5pe(Shipping name,and are cla55ifted,p CD <br /> T.arked ana faGeled;piacarded.and are in all respects in proper condition for transport according to applicable internationaland national govemmenlal regulations-It ex4ort shipment and l am the Primary Ol <br /> Exporter,I certify that the contents of this consignment contorm to the terms of the attached EPA Acknowledgment of Consent. IZ <br /> SO <br /> I cer thal the waste minimization slatement identified in 4g GFR 262.27{a)(if I am a large cil generator)or(b)(If 1 am a small quaniily generator}is true. <br /> tify <br /> Year W <br /> Signawre Month Day � <br /> Generator'srONero�s Prtnlad%Fyped Name IV <br /> V <br /> N <br /> j 16,International Shipments ❑Export From U�S. Pori of entrylexic � N <br /> F- ❑Import to US. <br /> z Transporter sionalure(far experts onlyJr ❑ate leaning U.S.: <br /> 17.TransporterAckrwwledgment of Receipt of Materials Month Da Year N <br /> �. Signature y <br /> tY TranSponer i PrintedrTyped Name <br /> L-- <br /> O <br /> Month Oay Year �Si nature Transporllet2Printedlryp0:Name 9 fD <br /> rD <br /> N <br /> 18 Discrepancy Q <br /> 18a-Discrepancy Indication Space Type ❑Residue ❑Partial Rejection Full Rejection <br /> ❑ Quantity <br /> O <br /> Manifest Reference Number', C <br /> U.S.EPA 10 Number r* <br /> lab-Alternate Facility(or Generator} v <br /> � N <br /> U 0� <br /> 7 <br /> Q Fal liry's Phone: Month Day fD <br /> 18c 5ignatureofA)female Facility for Generator] Q- <br /> Q <br /> C rD <br /> rn <br /> 19,Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems} �' <br /> 1 3 d. <br /> 2. <br /> N <br /> t? <br /> 10.Designated Facility Owner or Operator:Certification of receipt of hazardous materials covered by the in except as noted in Item 184 Month Day - <br /> Signature — O CD <br /> Frntedl7ypadName �'rc o <br /> GENERATOR'S ININI nnO 3 <br /> orm 8700-22{Rev.3-05) Previous editions are obsolete. <br /> T <br /> 0 <br /> v <br /> to w <br /> (D 00 <br /> 0 <br /> co <br /> 0 <br />