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co CD = o�-0 <br /> CD N <br /> 0 0 � O <br /> iv 0 Q o to <br /> O 3 O N <br /> CD G7 <br /> Q 3 <br /> O O C(D <br /> type. I [II I� FormAPPmved.OMBNo.2050-0039 <br /> .-ORM HAZARDOUS 1-GereramrlD Numaer 11101111 IIIE I� <br /> kin Number FLE `D <br /> WASTE MANIFEST L4E~$1e1�4.t4'I se Phone 4,ManNest7raC a <br /> 2,Page 1 of 3.FJnerpea Y Respan � <br /> t CD <br /> S.cenaratoir,Name and Mail,Address = 1:7??} 5'? � <br /> t 'P Generalors Site Address[if diaercal Neo rra�n9 address} W <br /> Genenlors Phone: odi. f{ .. pJ <br /> 6.Transporter 1 Compamy Name 0.5.EPA ID Nranber O <br /> :.ferxr—le Specials• {gy�rA4dF°114 '. . <br /> 7.Transporter 2 Canpany Name U.S.EPAID Number <br /> 6.Desgnaled Fal Name and Site Atldrese U.S.EPA IO Number <br /> v, 14V <br /> FaalitysPhone_ <br /> ga. 9tl-U.S.DOT Desorption(edudm ProperShi r <br /> gppirg Name,Hazard Class,10 Number, 10.Containers 11.Total 12.Unit t3.4yaste Caries O <br /> HM and Pecking Gmup(f any)) Q <br /> Quantity Wf.lVd. <br /> No Type <br /> D <br /> � co <br /> IQ <br /> O <br /> J <br /> 4. <br /> 14 Special Handling instructions and AddiSanal informaric I- --r <br /> 15. GENERATOR'SIOFFEROR'S CERTIFICATION:I hereby declare that the contents of this consignment are fully and acmraiety descnbad above by the Proper shipping name,and are classified,packaged, <br /> marked and laheledlplaarded.and are in all respects in proper condition for transport aeeording to applicable inlemationaland national governmerrW regulations.It export shipment and I am the Primary <br /> Exporter,I certify that The cements of this mrtsignre lConform to the terms d the attached EPAAi;nmvAedgment of Consent. <br /> 1 Perri that Ne waste reldni statement Identified in 40 CFR 252.27(a)lif l am a large quantrygeners r}or(b1 III area Small quantity generator)is true, <br /> slOfferors PrnledrTyped Name Signatp - Monm Day Year <br /> Sf/Yi <br /> 16.In[emabonal 5hipreants <br /> F ❑Import to U.S. ❑Export Item U.S. Pod of emrylexit: <br /> ? 7rartSpwlar eignature(lorexportsenly): <br /> Dale leaving U.S.: <br /> w 77,iraruponerAWnowlatlgmem of fieoelpt or Materials <br /> Transpow I Prromarryped Name Sl nature <br /> �O 1'dlnng i-rr'r'I'{;' g � � Month Day Year <br /> A h, <br /> Transporter 2 PrinledrTyped New Signature 1 S 1 <br /> OC Month Day Year <br /> F-- <br /> 18 <br /> 16,Discrepancy <br /> ISa,Discrepancy Indieatioo Space ❑Ouanlily ❑Type ❑Residue ❑Padiaf Rejection <br /> ❑Full Rejection <br /> 18b.Alternate Facilily(or Generator) Manikst Reference Number, <br /> 1 <br /> U.S.EPA 10 Number <br /> v <br /> 4 Facilitys Phone: <br /> � 18c.Signature of AlEemate Fatality(or Generator} n <br /> 4 Month Day Year C CD <br /> z O <br /> y19,Hazardous Waste Report Management Method Codes p a„codes for hazardous wastetreatment.disposal,anti recycling syslems7 D Q <br /> 1 2 7 4. _ <br /> ■ <br /> 20.Deetgnaled Factity Owner tar Operator:Cerafinbon of receigl of hazardous mafenals covered by file manifest except as Holed In Item Jae <br /> all ignalum N �l <br /> � O <br /> Month Day ear cn <br /> QJ EPA Form 870022(Rev.12-17}Previous edffkAs are obsolete, O <br /> N <br /> (D GENERATOR'S INITIAL COPY cn <br /> tat 1 !t. !1-' r -1 1 fly I l r:'4�r{� ` O <br /> o <br /> rn <br />