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FWASTE orm designed for use on 12- ' )Typewriter.) — Form Approved.OMB No.2050-0039 RDOUS, 1.Generator t mtier 2.Page 1 of 3.Emergency Response Phone 4.Manivflest Tracking Number i"�i'T..'.3'� ""M FEST C l£: . 0 4 1 t- I Q700!4 w:';p s, (.!` 1 0 ,: JJ K 5.Generators Name and Mailing Address Genres Si a Address(if diAerent than mailing address) Generators Phone: 6.Transporter f Company Name U.S.EPA ID Number - ,`4cf;�RY s,A 0,C, ' 2 i i b 3% Z Transports, pany Name' U.S.EPA ID Number 8.Designated Facility Name and Site Address U.S EPA ID Number 12!)0 P=tith`is; I6fli Facility/s Phone: v:_.J! 9a- W U.S.DOT Description(indudmg Proper ipptng Name,Hazard Class,ID Number, 10.Containers 11.Totat 12.Unit HM and Packing Group(if any)) No. Type Quantity WIN6 13.Waste Codes 1 r3".sd't l� iF'r""?bN5 1 A^.'S`tE �¥S�01D'ia):i 41, Z 2. I lu 3.4. i i i 14.Special Handling,Instructions ar)d Additional In ation _ 1-5i t,''- J�`fe r r •.1�__ } ~^ ro •Ee iiY,�C-> p".rt' is'rvts�s!# f�?b?�.� yf•'�.��f � tLw �: -_.ary.t 3... 4;td:.h4ykfii:a-- (' 4"4�3XI '.'•f Alii 3P 1-447 Q ItRi P.FR PROG PfAm `.:< APPA-07F?;T£F`£R40X1.AL PROr£.CTsk�:;`J1^<ui 15. GENERATORWOFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by the proper shipping name,and are classified,packaged, ,marked and labeled(plararded,and are in all pects in proper condition for transport accordi ng to aWhcable international and national governmental regulations.If export shipment and I am the Primary Exporter,l certify that the contents'ofthis nmentconform to the terms of the attached EPAAcVwwlf"dgment of Consent I certify that the Waste minimization statement'entified in 40 CFR 26227(a)(d 1 am a lance quantity generator)or(b)(#I am a small quantity generator)is true. GeneratorslO6erors Pdntgdffyped Name Signalnre I f Month Day Year J 16.16temational Shipments ✓- G— ❑Import to I J.S. ❑Export from U.S. PWof entyiexit: Transporter signattire(for exports only): Date Leaving U.S.: W 17.Tr-dnsporter Acknowledgment of Receipt of Materia Is X Transpoiter 1 PdnW/Typed Name Signature Month Day Year O a QTransporter 2 Printedriyped Name Signature Month Day Year (1' 18.Discrepancy 78a.Discrepancy Indication Space ❑ Quan' Type Residue Partial ❑ ❑ ❑ Rejection Full Rejection Manifest Reference Number. 18b.Altemate Fad%(or Generator) U.S.FPA ID Number J U tai Fadityrs Phone: w 18c.Signature of Alternate Facility for Generator) Month Day Year Q z -- N is Ha;,r(kvrc Wacita tzap«+M—gornont Mdr,od eo m(i.e.,arzks run hazardous waste treatment,disposal,and recycling systems) 0 1. 3. 4, 20.Designated Facility Owner or Operator.Ceffffimbijtri of fecapt of ha72tdous matenafs Wyk%d by the maridest except as crated in Item 18a PrntedrtypedName Signature ,t Month Day Year EPA Foran F00-22(Rev.3-05) Previous editions a#obsolete. GENERATOR'S INITIAL COPY