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Please print or type. Form Approved.OMB No.2050'0039 <br /> UNIFORM HAZARDOUS I Generator ID Number 2.Page 16f 3 Emergency Responso Phone 4 Manllsst TracFing Number <br /> WASTEMANIFEST 1 11! <br /> 5 Goneraror's Name and Aielling Adtlress (3ansratoes S9oAtldrass eldimuentTon mawit address) <br /> Generaluis Phone: <br /> 6.Transporter l Company Name U.S:EPAID Number <br /> d.Transpatar2Company Narne US EPA DNumber <br /> 8.Designated Facility Name and Sire Address U.S.EPAID Nbmber <br /> 1915' I� i0l tl'.`t" ry f fr•r+)xii r,t, Wv <br /> Facie 6Phdna:i7;.:r.'f c,' i` <br /> ga, 9lx.U.S,DOT Description(Irducene Proper Shipping Name,Hazard pass,ID Number, 14.Carrlakrers <br /> HM aMPaukNck rp(Hany)) No. Type Quamyy mm. 13.Waste Coles <br /> 4a <br /> 3. <br /> 4. <br /> 14,Spector Handling lmsbue6ana and AoiaoW information - <br /> ",ri�� ra h. it ft�rr lr ir' •ri-1 Sri ='FC <br /> 15. GENERAT0R'8/OFFER0R'S CLVbFICATI0N: I hereby declare Tat the contents of eds tansignmenl are fudy and accurately described above by the proper stripling dame ant are dassffiad,pao..all <br /> marked ane IabNed<plxarded,end ere m al respects N poper cdrt6kbn f«transpol aavrcwg taeppilcabia InteseaeoraiaM naearal govermentai regulations.rcexpod shiprlsen!and I am IMPrmury <br /> Expale,l certify that die wmenls d rias cpnsigarpnl oinfpm(0 0* mp of U*Mt W EPAActnow*igm of Consent <br /> I Cefty that the wawa minimizaten statement lJoWled 4 40 CFR 262.27(a)(d I am a large mrantgy genera(«)a(b)(ill son a small planoty generator)Is Cue. <br /> Generarm'slOAeoh Prinwypet Name . -.: SgnaWre. - Month Day Year <br /> 16 Inknlatlalal Shipments <br /> qtr ElImgpt n U.S. ❑Export from U.S. Port of entryleut:__„ <br /> E Trantporrlersignatae(breWahaVy): <br /> Date kavirg U.S.: <br /> 17,TranspaferA,dDoxledpneltafRacelplWMalariWs <br /> Transporter I Printed?yped Name <br /> p M" Dry Yex <br /> Twspoter 2 Printed?yped Name - Signature <br /> Abn71 Day Year <br /> 18.Discrepancy II--�T <br /> 18a.Discrepelcy indication Space El ctuanby, © �r�y---7I EJ <br /> Type LJ Residue ❑Parcel Re)eclbn Full Re s <br /> I e[raneaNu <br /> 186.+NlernaleF«9iy(or Generela) U.5:EPAIDNumber <br /> 'U <br /> LL Fealty's Phare: <br /> B lee.SignaWrs of Alternate Fadey(or Geneda) Month Day Year <br /> 19,Hazardous Waste Report Management Medrol Cafes(I.e.,codes la hazardous waste treabreriL dispow,and recycling syste") <br /> 4. <br /> 1 20 Designaled Fogy Dom a 0i's"no'Cei66catlon of recelpt of htaedprs materials covered by the manNasl except as Med in Item tea <br /> PrnrhdrTfPed Nanre er Dat Year <br /> EPA Form 8700.22(Roe 92 17) Arari4os editions are obsolete. GENERATOR'S INtT)AL COPY <br />