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orm Approved.OMB No.2050-0039 <br /> a Ar. page I 0Emergency Response Pholne j 4.Nan fest TracMnja Number <br /> c <br /> ?0 013120796 FLE <br /> Genera7p;'-s 77-Address Vdiffen en"than mading address] <br /> 7'e":-ISP"Fl-�t 1 Cot-pery MaMo U.S.EPA!D Numoar <br /> cry NIc'me 16 NUrnber <br /> Ut E7 <br /> Site Add:-ss <br /> e U.S._ AID Number <br /> Fac.lis Pnone`. <br /> 9�.. 9b.U.S.00. r Prace'r ShzPping Name,Hazzaid Class,ID Number, 10.Contai,ers 2.U ri ill 13. "Vas4e Codes <br /> No. Type <br /> ill 11111 and--a-kmg Gi-c;'to;if any�� Qu entity 1616ivol' <br /> 0 <br /> Z L. <br /> C <br /> 11 I <br /> '1 <br /> 8 <br /> 4,Spec a! n d1ling to °c and Additiciai nforMation <br /> 11, GENERAORS iOPFEROR'S CERT FCATiON: 1 hereby deo are thatine contents of this snnm,nt are fully and accurately described above by the proper shippin-a name,arc are aassliied,packaged, <br /> �--cirkad and labeled!plalcc-lrded ar,+d are, re.peclS in proper cond;ion for#rans,Poi,according-'o appi,�cable;n'te,,natiar.a'and naluonal govermmemal regulations.If expor'shipment and i am the Primary <br /> v of e a,ch d P A n , d m o <br /> COW01 m to -F e. it@ a E A Ok owle g ent 'Consetit. <br /> a large puantjtygenerator�or(bl(if!am a small qu niltygenerafor)is true- <br /> Ge to6oknw%NrlwfrypSiq <br /> afore ivtenth Day Year <br /> import to U.S u Export u S. -or,of e'"t,".1ea <br /> Trarlspoits,sigq.�tuo(for 6/11pai's only;: <br /> Date leAing U.S <br /> ransporta r Actnowleacmtat i?i Rcc--Ipt ofiviatertals <br /> T,`Isponnniad,,TvPed Namea�jna Nlonth Dav Year <br /> -:7 <br /> "carts 2 <br /> ,ped Name <br /> < M,o n t h Day Yea: <br /> 18a,C Crind, <br /> Type Residue <br /> JAr,,;,es:Reference Numbe <br /> tu- r: <br /> 18b.Alternate 'c(Genar3 , <br /> U.S.EPA ID Number <br /> ibc,9iu rc c: Fac4lity(of Gerenzjo;) <br /> --71h Day Year <br /> 19 Hazaor-uls!tVase Ropor"N13-6: nent Oe'rhod Codes ki,e-code,:for hazardous vias:,treatment,disposal,and recycling systemis) <br /> LU i <br /> 4 <br /> 3. -4. <br /> i' 't <br /> 2C -ry-�signalec�Fa-At�&w!er or Cpe-, w1r Cetficatlon of receipt of hazardaus nater'a. cove; d by rynfe exce,oas noted n4 nTA <br /> a,' <br /> St <br /> me goaturs x Month Day Ya- <br /> P <br /> E PA Poi nt 8 TO-22 IlRev. 247) P—vio;.s �,n� <br />