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-.;,•.-f-s�-. air "�:s.�-;'� 4r-s�. <br /> Please print or type.(Form designed for use on elite(12-pitch)t)pewriter.) Form <br /> ' Approved.OMB No.2050-0035 <br /> UNIFORM HAZARDOUS 1 Generator lD _ ! 2.Page 1 of 3.19enop Response Phone 4.Mandest Tracking Number <br /> ! WASTE MANIFEST �rl� 2GBF <br /> 1 [v v t <br /> s.rae r ana Many address i zl �rfi1 F !A �'If r ?°Ii Y;i r s Site Add (if Wer t fan nailing address) <br /> Generatoes Phone: <br /> 6.T7L1Corrgarry _ <br /> 1.Transporter 2 Company Name U.S.EPA 10 Number <br /> r <br /> 8 <br /> 0-93awfacpoame and Site Addre a 3 y/}L f U.S EPA 1D Number <br /> 9b-U.S.DOT Desrptior,(including Proper--LName tt�ard t Lass ID t4rsrdrer, 10.Goners <br /> 9a11.Total 12.Urld <br /> -> HM am P-a"g Grrrup"i)), y z No. Type auartity WLivol. 13. le Codes <br /> 1.0 <br /> lz <br /> UJI <br /> k <br /> 3. <br /> ar - <br /> 4. t <br /> 14.Sncca!Ha dlingg lrstrlCu�cjtjrors ano AMtUorel In)Er, <br /> 15. GENERATOR'SfOFFEROR S OUMMATION:l4ereby declare that the contents of this oansignment are fully andfacaxatefy descwbed above by the proper sttippurg name,arca are Bassi ed,packaged. <br /> marked and tabeledrplararded,and are'sm all nespec4s in proper mnd>rion for iranspod according to applicable n erratiord and national governmealA reWiabons.ff export shprnerd and I am the Primary <br /> Exporter,I certify bat the contents of flus consignment confom to the terms of the a+3ach d EPA Admowledgnent of Consent <br /> I certify that the waste naramizatiion statement iderdi*in 40 GFR 28227(a)f6 I am a large quari4ty 9—tor),-4b)Cd tam a small quantity generator)is true. <br /> t�areratrrrsro*We Pwledrfyped N <br /> f , sigmtup s+orir -Day ,Year <br /> 16.International Ship rams } <br /> F !J Import to U-S F]5pat Yarn U S. Port of entryie>Ut — <br /> Z Transporter vgnatrre(for exports only): Date leaving U.S_ <br /> t�tr 17.Transporter Aowledgrperd of Reexipt d Mat <br /> Transporter 1 PratladfT tJarite s �- sig aeue f Mordh Day Year <br /> 03 <br /> TransparW, PmledffypedName Signature Month Day Year <br /> t- <br /> 18.Dsuepancy `` � <br /> 18a.Discrepancy Indicaton Space Elt1 Type ❑Res due L�f Pa+tiat Refection i J Full Rejection <br /> htMest Refefwm Number: <br /> I 8b.Alternate Facility(or Generator) U.S.EPA 1D Number <br /> C-3 <br /> ti fasWs Phone: <br /> W 18c.Signature of nitmnate Fadfiry(or Generator) Month Day Year <br /> a <br /> z <br /> 19.t n`7ardws ftste Repor?rAwagampni Neihad Codes t ..codes nr hambais waste treatm ni,Msposai,and recycling systems) <br /> UJ 1. t 2 3. 4. <br /> i Ll <br /> 20.Oesigna�d Fat�tY Or,tlet a Opes3tof:Cta;itgl t>f �of ha^lardo»s rtt2lt�iais by it> ntat�est exc�t as rwred�n.�t�n 18a -h <br /> f mr dffypw Name - Sgnah"t. - ' _ j } hAmran Day Yew <br /> EPA Form 87OD-22(Rev.3-05) Previous eddmns are obsplefe. <br />