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Please prinE of type.{Porn'designed for use on elite{i2 pitch}typewriter.} bI✓� C' f, - L Farm Apprpved.OMB No_2U50.O739 <br /> UNIFOR�HA7-ARZDOUS 1.GeneratorTI}Numher 7-Page T o1 a-finer9ency Respunse Phone 4,MMaanifest TrackingNrrmber <br /> WASTA�CJDD t3 177ya 2 (877) 577-.i' OQ O DAT <br /> 5.Genemtw's Name and Malbag Address Gcneraiofs SdeAddrnss{iF diHerant than mail ng oddressJ <br /> ITS LON STMES 116 LOIS 14M <br /> 20a PRIalp RD RTTH: DENA FERAR0 111 5 CHEROKEI- UNI <br /> Generators['bone: MOM 10H 43220 _ f�z�3�re-zraa 11_011 Cif 85245 <br /> 5-1 ransporter 1 Company Name U.S.EPA 1D—M, <br /> STET ICYCL E SPECTAL'T Y UP5TE SOLUTIONS hlC MNS0 00110924 <br /> 7.Transporter 2 Company Name U.S-EPA IO Number <br /> B.00signated Facili y Name and Site Address U-S.EPA€D Number <br /> 2'ST CFki U RY 0ffj Y()NMFNTPL PARA&D. MI f OF WY€DA, LLC <br /> 21145 Reulands 1ive East <br /> [iMTW <br /> q.R!LEY 0 89409 075!S.007 Descripllon(includiag Proper Stripping Name.Hazard Class.0 Number, 10.Containersackitrg Group(ranyj) Ti-Totai 12 Unit <br /> No- Type Ouanlily Vrtfvcl 73.WVasta Codes <br /> 1 <br /> 1:41111: <br /> O ' <br /> u.t _ <br /> � r - <br /> e� t <br /> T <br /> I <br /> 4. <br /> 14.Special IlaiWII l tstn,cdons and AAdWOnal In€ormalmn <br /> i <br /> 7- t <br /> 15. GENERAT011WOFFERDR'S CEiRT1F3CATiDN:I hereby declare that the cpntents of This consignment are l*and armraielydesaibed above by the proper shippingnamn,ani are c€ass+Ged,packaged. <br /> marked and labele&ptacarded,and are in all WWI in proper condkionfor transport according to applicable intemationaland national <br /> Exporter,l c(Mify ftW the conlents of Ibis can*omenl conform to The terms of he atlantad EAAAckrww flovenxadnlai regvlal ons,N expod Shipmuni and 1 am rhe Primary <br /> 1 Car*that the waste murmira6on staleiml identified in 4n GFR 2$2.27 a dl am a large sant, deo!01 Consent <br /> {1 C s 4 1y generator)or(b)(if)am a sinal!quan8lygwaralor)is lrue. <br /> GaneratorsfOHerara Printed/Typed Namc Signature <br /> t r I-i Month Day year <br /> ❑ LA—r 15.Inlameticnat5hOrranls, ! ' <br /> import to U.S. <br /> ? Transporter Signature(tor exports only): FxpoR from U.5. Port of enlryfeXft: —,T— <br /> W 11.T-m sPW"AckxWLdgrneMofRocaipioft9ateriats 6ateleavin9U.S.: <br /> Transporter 1 PrhlediTyped tdame <br /> III LS [ gnalure 'Annlh Day Year <br /> Tronspoiler 2 ed yped N me )7 <br /> Signature <br /> Day Year <br /> Is.Discrepancy - <br /> 18a,Discrepancy Induction Space 4uanaty ❑Type tI��1 <br /> Residue Ll Partlat Rejection Dull Rejection <br /> 1815 Altemale Faalyy(or Ge,teralur) Manifest Reference Number: <br /> U.S.EPA 1D Number <br /> U <br /> ++¢ Facdily's Phone: <br /> UO 18c.Signa&ue of hllemale Faril;ly(or Generator) <br /> Month :1)ayIYeaf <br /> 19.Hazardous Waste Report i,e2n89ernenl Method Codes(i e.,codes for hazardous waste€realmenl,disposal,and recycgng systems) <br /> GJ <br /> 3. 4- <br /> 20.Des)nated Faepily Ovww or Opera :C8f6frcarion o1 retetpl of hazardous materials covered hY the rrtanHest ezcepl as in(tern 18a T ^� <br /> PriNedlfyped Name Signalu6V67 1Na NY <br /> ear <br /> EPA Farm 870[1-22(Rev.3.05) Prevjou sr3iiions are obsolete. <br /> DESIGNATED FACILITY TO DESTINATION STATE(IF REQ I D) <br />