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PEeasa:print or type, � �. <br /> UNIFORM HAZARp00§. I.Generator IO Num* <br /> WA57E.AgANtFEgT ;F :,? �j:.r 2 Page i aF .3,Emergency Res .e Ffior e. Form ApWOved.OM$.No:X050 003 <br /> s14 4.Manifest Tracking Humber. <br /> 5,G�neralo�s IJama and klarrfag Address <br /> r;-:• .,:.,�.... Gen earn'sSiteAdd i 0 292n <br /> 7 ItdttnI than mavag address) C <br /> Generat'Des Phone:. s:? <br /> Trans <br /> porta r f Company Name D. i wow <br /> c •:<.< <br /> T.Transporter 2 Corn . » - - ,, U.S.EPA 10 Number <br /> pany Name <br /> w:.... <br /> e.Des gnatatl FaclFi!Y <br /> U-S-FPA iA Humber <br /> Name and Ste Addrass'-2 f,i;+r 3 I <br /> [1,5,EPA ID Number <br /> Facifiry's Phone: <br /> 1`5.`4;r <br /> Ha. 9b..U.S.DOTi7escrfp60n:(irrcluding.Pmpsr h Aping Nai teresnNufte,,fl) - "f"' <br /> kkf .and Packing Groilp„ifany)} <br /> 10.Conta!ers <br /> f:' r r 11,7ofal <br /> . _ -aY< :s. C. No. 12.Unit <br /> O r.E: s' rYpe Guan1'ity WtJVoi. i3,..Abste Codes <br /> JI <br /> w <br /> w <br /> g• <br /> 4, <br /> 14;Special Hardlin9 EaslrWions and.Addttianaf information s. a rrc5 c <br /> 72, <br /> 15. GEIVERATpRS1edl Ela 12=5 CERTIFICATiDN;t hereby dedars lhat the contents of this cans gftrrtent are fully and acd irate) des <br /> marked ard:tabetedfplacarded,and am N ali.res <br /> Exporter,t certify Ihat the cdntents of this cans gn afo mrf the t rm of the aH aocvrdi Y cob above by ft pro r i ' <br /> f cern p EpA n9 aPpTrdable fntemationaland naGonaf p op' name,aid are dassifisd, <br /> fy that the wasle mfnRn 006.5 is identlfiedfn 40 CFR 2fi a rf i a n a large q i1C.kpav� pvemmanNl rmgulatlons.:lf a packaged, <br /> Gene i.)r fedgmenf 0 sent.. stdpmenl and I am the Primary <br /> ffero-Cs Printed7yPed Name �Y generator} {b} am small <br /> a u <br /> $. 4 hh generator}f5 tore: <br /> 1fi n ernatiahal.. h parents. l�-tMonth Gay Year. <br /> .rat�!import . <br /> . nsponer signature. <br /> tFo-rexpods:onlyJ to U.S: 1EIExpo-rt.tm S, Portal'nlrylexi <br /> u�i �7-x Aclir�wle tgmeet of l7ecgiprar futatr is <br /> .Transporter 1 PrtntedlTyped Name eteal <br /> V] •”` S nature <br /> Traosporfer 2 Prin[lWTYped.Name MoathYear <br /> Signature 0aY <br /> 7$Det epancy Mdnlh Qay Year <br /> 78a.Dfscrepancy Indiealfon space <br /> U+raRGiy <br /> ❑Type <br /> Residue <br /> ❑Parflat Rejecitgn <br /> F� 1Ra,Alfeniate Fac li Frif}Rajechon <br /> ry{or Generator] <br /> Manifest Reference Numtier' <br /> U <br /> Fac lity.'s.Phvna: U.S.EPA 10 Number <br /> :19c.Signature ofAt[ernate Faciifly.{or Generator} <br /> f B.Flazarddus Wastia sport tanagemeni kdeltwtl Co-des.{i,e:,codes for hazardo s waste treatm Month <br /> W 3 OS Year <br /> 2 em;:dispo'Arr and . <br /> me !n s ste <br /> g. Y ms} <br /> 3. <br /> �o-Designated Pec' 4. <br /> oar drOperalor_.Cedfcagon of rscalpt of hazardous ma! H' <br /> PriRledffyped Name: covered by the as manifest exce f <br /> p ruled fn 18 <br /> 5!gna <br /> EPA Farm$700 22{Rev.12.17) Prsvfotas.ediffons are obsolete, month. Dar Year <br /> S Y DESIGNATE..FRCI 7 Y TO EPA's <br /> ,.a..1087 1 .Xf;,- .. : e•MANIFEST.S ' ;TEM <br /> _.. <br />