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• r r r • r ' rr r • r • r i 1 Ii • <br /> i _. . <br /> Generator ID Number <br /> mergenc <br /> esponse Phone <br /> 5, Qenerato Generator's Site Address (if different than mailing address) <br /> At s <br /> - ' , ` -�, <br /> I <br /> ' <br /> • � TMp , • <br /> ogmm, Inc. <br /> 7, Transporter 2 Company Name U.S. EPA 10 Number <br /> 8, qefA2ftJqft.Name and Site Address U.S. EPA ID Number <br /> 6300 Stadium Or <br /> Kansas Cfty MO 641129 <br /> ' , U.S. DOT Description (including ' r , • , , Name, Hazard <br /> . • Number, I I • star 13, Waste Codes <br /> 11, <br /> and Packing Group (if any)) <br /> • 1 <br /> 1 pe ia an <br /> • ing nstructionsd Additional <br /> r - e> Y 0 - <br /> marked15. GENERATOR'S/OFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by the proper shipping name, and are classified, packaged, <br /> and labeled/placardedand are in all respectsproper • • • for • rrt according to applicable internationaland national governmental regulations. , • • , <br /> Exporter, I am the Primary <br /> • of 1 • nment conform to the terms of • • EPA Acknowledgment <br /> I ceitify that the waste minimization statement identified in 41 • • quantity generator),V(b) lift am a small quantity g true, <br /> Generav<!eroes Printed/Typed Na Signatu (P Month Qlay Year <br /> 1 ...International • . t <br /> import to U.S1 El Export Port of env-p' 6'X'it: <br /> fro/ Date leaving U,S.: <br /> Transporter signature (for exports only): <br /> 17, TransporterAcknowledgment of Receipt of Materials <br /> PRIAM <br /> � Month Day Year <br /> } <br /> N me �j` <br /> TransporterLL 171 1 Zc) <br /> IM I <br /> FF <br /> , . , i <br /> • _� A 40 <br /> �r <br /> ' D . <br /> y Year <br /> 18a. Discrepancy Indication Space El Quantity El Type F1 Residue Partial Rejection EJ Full Rejection <br /> Manifest Reference Number: <br /> ' 18b. Alternate Facility • Generator) <br /> Facility's Phone: <br /> 18c, Signature of Alternate Facility (or Generator) Month Day Year <br /> : 19. Hazardous Waste Report Management Method Codes (i.e. , codes for hazardous waste treatment, disposal, and recycling systems) <br /> 20. Designated Facility Owner or Operator: Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a <br /> Printed[Typed Name Signature Month Day Year <br /> . . r 11 • . • - r ' r r rr r . . <br />