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.septl'1RDf'#ype� 4. TraclthfgNsutber <br /> } Geneta�>r IQNurr�r :.Page 1 0! 3 Emernerc!ResponsePtrerte <br /> �MI +, � l -�, 012177674 JJ <br /> WASTE MW C,�C o� <br /> �� �• ,T+ Gettnra? es Spe A,:drpss t't!N'!P,(P.(tt L^a^n1314G14 d('d-e551 <br /> 15.Gene lix's Name and Ma ling AdwessAmin <br /> 7►/ i <br /> ��D13�1- tytRT�II" L AtW <br /> S-1-,OrKTb tv <br /> Generator's Phone: 7 U.S EPA ID NuMW <br /> h.7farPSpO r 7+cmpany Narme <br /> i, 1ST ► <br /> U.S.EPA ID Number <br /> 7 T,arspo ter 2 Company Name <br /> s.Des;yn3tad f=acility Name and Site AWreSs .w1 / .,1�-�), /� a U.S.EPA ID Number <br /> CK.►',`�>f O t nvlf'SK /i kit 7 <br /> feew,e,�xj CM/ CA IR39 <br /> Ga ikt}'s Phrx e �,- <br /> 9a. 9h U.S.DOT Description Including Proper Shippn�Name.Hazard Class.iD Num re. ENo. <br /> Containers 11 Total 72.UHC 13.1Yaste Codes <br /> NM and PaLMN GroLp(•3 arn)) Type Guan$ty Vd IV6. <br /> (OILY bo <br /> r <br /> 14.SpP.dal NahrflirV InsfnictW Addib"'fnFama <br /> q,4i � CA 6� �k6 <br /> 15. GF CERMCATION.l h eby'declare etri N contents of ns coneignrrient are fully and accurately described above by the proper shipping name,and are ciasshed,peek2ged, <br /> marked and iabeta 0acarded.and are m all respecls in proper condition flu Uansport a=ding to eppiitaWe international and national govemrmental reg?.Mtions.If export shipment and I am the Primary <br /> Exporxr,t ce tidy that the contents of this Irons grime. corAonp to the terms of the a9ached EPA Ackwoiler."nt of Consent. <br /> certifytrtat the waste minimrm(w sbtement dem in 40 GFR 262211a)lif i am a large quantity'generator)or(o)(dI am a quantity generator)is trim. <br /> Generatce �V PrintedIT Name i S gnahxe Maw D Yea- <br /> . r � �Crxc�� !4 : 2 Z,3 0 <br /> 1G.IntentaGonal shipodent <br /> (—j <br /> Q Import to U.S. L_ Expos from U S. logofentrylexd. ------ ———------- .. .. <br /> TrAMPortef signature(for expaAs qW - Date leaving U.S.: <br /> 17.TianWoirer Admo+idedyment at Raceo of MawwL <br /> 7 i PrvdediTIfW Name Srgrmture <br /> ce- Month pay rear <br /> o Z. l <br /> a <br /> ? Trainilporter 2 PMtKTypw Name Signature �=w <br /> Month Day 'rear <br /> 16.Discreparcy <br /> 18a.Discepwcy+nacatian Spars Q QuantAy I ❑Type ❑RestdtreLJPa tial Reject an <br /> Q Full Releeban <br /> - Mantfesl Relerence Number: <br /> I8D.Ateamate Facility(rn Ge(reraror) - <br /> U.$:EPA ID Nurnbet <br /> V <br /> U- Fadiitys Perone: <br /> w Iflc.svakee cf A9emmy ale Fa (or Generator) <br /> ZMonth Day Year <br /> 19,Hazardous Waste Report Management Method Codes(4s,codes for hazardous waste bwtrrient nlsposat,and recycling syseents) <br /> 4 <br /> tri.Designated Fac ty U rner of Uperabr.Ce*Dlica <br /> Dturr or gt of Hazardous materials covered by the man test except as salsa in"em tea <br /> AP671*Name Sl nalum <br /> Alonth p� Yea <br /> EPA Form 8100-22(Rev,3-0-1) Previous editions arc nh tri. 'i3ESIGP3ATF -ACtLjty rO DF-STINA'TION STATE fllF REQt11[3E�jt <br /> - y <br />