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P I ease print or zype.(Fornt designed f9i US?'?n a I ite(1l patch1.yPe _rt tei." Form A-proved,C`,13 Me.2050-009
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<br /> U, FORM HAZAR�O US ler
<br /> WAST_MANIFEST F
<br /> 011385113 F L E
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<br /> �c,,a Nomear�,klailmg Address Generam`s Sate address;ifd,_ffer-_N I-,In ralg-Iijdtessli
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<br /> Generato,Phone: rA
<br /> 6 T Mmuder I Comoan',Nam, U C EPA D M mber
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<br /> 8.Des gnat. Facility Name anl Me Address D ML mib,
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<br /> Qb.U.S.DOT Description(including Proper Shipping Name.Hazard Class,ID NumW, Q.Containers 11.Tota' 12.Unit 3 e C 0,j s
<br /> Prt -rid Packing Group(:i any,,, talo. Type Q- ;rte.
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<br /> Handlkng ristructons and Additional Information
<br /> 15 GENERATOR'51OFFEROWS CERTIFICATION: 1 hereby declare that the contents of thi's consignment are-fully and accurately described above by'he proper sniipcing rarne:and ere classll_o.PP-cl<aoso,
<br /> marked and abe'eJhD'carded,arid,are in all respects in proper condition foi transport according to applicabie international and nai.onal governmental regu!auons, export shioiner!and Ian the Primary
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<br /> a-1 certify thai he contents of tris onsion ant conform to tine terms of the attached EPA Acknovdedgmen,df Censer`..
<br /> that the min �ation statement'dentified in 40 CFR 262.271(a)(if I am a large quantity generator)or(b)(if I arn,a small generato,-)is irie.
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<br /> a,&S!Olfl�f�qrs FtrntedTyped Name Qna}ra ar
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<br /> ,n international Shipments
<br /> i 7,Inlip"It 10 U.S. Export frot/u S'. Por.,of entry,'aV,:
<br /> T ransuorter signature(for expo tsonly,=_ Dale savirio.6,S-:
<br /> W !7.Tiansp,,r:erA-.kiiov;ledcin,er,.t of Receipt of Materials
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<br /> ran not I Printedilyped Name S glature Mon. ar
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<br /> 5;gnatqr-, Nlon;, Day Yea;PrintedTypeq Name
<br /> 18,Discrepancy
<br /> Discrepancy Indication Spacce Quamil�y 01 Tyre Residue P_ a� Fu"Pieecho
<br /> Manifest Reference Numbei! -PA ir"Nu
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<br /> (or Generator) U.S.'=Pa D
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<br /> Facility's
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<br /> loc.Sgnore oft Alternate Fa�i!Ry�cr Generaol)
<br /> 191,Hazarjous,Viste Report:tanager Method Codes(i.e.,,codes for hazardous waste treatment,disposal,and ecyclhlg systems,
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<br /> 20.De6igra,ed Fadily Cwneror Operaicr:Ceti fication of;ec_-ipto-.'hazardous materials c vdred by men fie exc�ept as noted in Item Ise
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<br /> Si r, Day Typed NatTka
<br /> 8700-22(Rev.3-05Pr v�u..F is n;Ons are obsolete.
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