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SSL SK 3H I R8 <br />LMOIpM <br />e }�•R: <br />- + y} 4 L 4 ��V• LVwvVu.7 <br />••' w. <br />�LL�/Lpp► <br />PMARD0U$ <br />1. Generator ID Number CALSS&� <br />2. Papa of 3.meY RM000re PUlope _ �1br <br />•' �"4� 1 lbs <br />,,ww mANIFEBT <br />9,r,ennmet7re� Name and Map*V Address . Gen*r aWs Site Address (if different than mating address) <br />y �y <br />rknAS 2 !.Y`l�;moi 1� Almy o%RbgV <br />1is�►'!�-4"-1'698 <br />4.f 7'TO <br />Garreratars Phare:. <br />"Tf r}� SYSTEMS INC U.S.EPAIDNumber TXROOM1205 <br />Transporter Canpany Nam U.S. EPA ID Number <br />MEAN HANSM ENV SVC INC. MAa4.39322258 <br />Designated Faci ty Name and Site Address SAM HAFMOR13 ENV I TAL. SERVICES, IN U.S. EPA ID Number <br />2247 8 HIGHWAY 71 <br />KIMBALL. NE 69145 <br />-398-235-4812 hE aI723513 <br />FacMWs Phone: <br />ea. <br />9b. U.S. DOT Description (including Proper Shipping Name, Hazard Gass. ID Number, <br />10. Gontai ars <br />11. Total <br />12. Unit <br />13. Waste Codes <br />No. <br />Type <br />HM <br />and Padang Group (d any)) <br />Qua" <br />WLAfd. <br />X <br />1' UNIffs3, WASTE PAINT, 3, P9 11 <br />ant <br />� F <br />P <br />F083 <br />F005 <br />0081 <br />� <br />� <br />000 <br />080& <br />213 <br />4. <br />4 <br />14. Special Handing Instructions and Additional Irrformetion T$a I _; ' " > 810876717T CSO t <br />ERB <br />24H ncy akuthori-}- a�dB; <br />15. GlEMMTt3 8l0FFRWS CERTlWAT=: I hereby declare Mg the om Wb of ft const mod are t* and aco"Aly described above by the proper shipping name, and are r saifiad. packaged, <br />rnww and Mbdediplacanded, and are in all respects In proper condition for transport accooilrng to appfi "i ternatianai and national governments! regulations. ff export shipment and't am, the Primary <br />Exporter, I eerfify that: the cantarrls of #0 kxxMoWlent oantorm to 90 tarmS of Ore aaaMed EPAAdnowledgment of Corsent. <br />I ®nMjr ilnat gieireste mirin®Gon stoton►eett IdenYAsd In 40 CFR M 27(a) (if I am a Mrpe quantify generator) or@1 fill am a amaN quentlty generator) as true. <br />GeneraloesK&Ws Prin&fyped Name re MOM Gay Yepr <br />1Q. ShIpnlBllb ❑ Import I, U.S. ❑ Expat born U.S. Part of erdrywt <br />Transporter signature (ter expmis only)• Date IeavYg U.S.: <br />17. TMh.,W0srA&nowl@dgijW of Receipt of Materials <br />Trans~me 5igrraWre Mont'! Day year. <br />Transporter PWryped Name 'Signature Morgh Day Year <br />18. Discrepancy <br />1S& Discrepancy Indication Space � [:]Type ❑ Residue ❑ Partial Ratek tion ❑ Full R"ecdon <br />Naft Reference Number: <br />18b. Alternate Facity (or Generator) ` a U.S. EPA ID Number <br />J_ <br />V <br />9& <br />FacOWs Phone: <br />10c VMn of Main* Fadtily (or Generator) <br />Month Day Year <br />S219. <br />Hasidous Waste Report Mecepemenf Metirod Coles (Le., codes for hazardous waste treat nenl, disposal. and racicir g systems) <br />caLLI <br />1. 2. <br />20. Designated Facility Owner or Operator: Ceftabon of reoW of hazardous materials covered by #* montfesl except as noted in Item 180 <br />nbmVT Nem* Signature Month Day Year <br />EPA r; o z le z� a7)_ � ous eanlans are o0swaffi. cit-NLKAl Arco tut i tot. wrT <br />y <br />