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M (nC) U) <br /> CID = ---4-o <br /> CD O o <br /> n --1 , c <br /> v Spon <br /> o Dov <br /> CD0 CD <br /> w <br /> T7 Please li I II I ISI fl�II Form p50AQ39 0 to <br /> M print or type, II III III III I I I q,Manliest Fratking Form <br /> Approved.OMB No.2 <br /> = UNIFORM N 1 Gene ale Ip Number se pfwne mbef O <br /> AZARUDUS 2 Pae 1 of d.5 I <br /> WASTE MANIFEST 9 Emergency Respon O 13�' F` (p CD <br /> 5.Gene[a1of5 Name and Mailing i address) <br /> rig Address if different <br /> than mailing <br /> Generators Site Address( � <br /> W <br /> Generalor5 Phone:1 Company NaN)6.Transporter Name CD 5.EPA Ip Number (n <br /> O <br /> 7.Transpprier 2 Company Name U.S.EPAID Number = <br /> N <br /> 8.Destgnaled F—iry Name and Site Address„ U S,EPA Ip Number =3 <br /> i (D <br /> FaaNhIs Phone. <br /> 96.U.S 130T Desai lion(including Proper Shipping Name,Hazard Class,ID Number, 10.Canfainers 11.Total 12.Unit O <br /> 9a. P ( rig pe PPing 13.Waste Codes Q <br /> HM and Packing Group(Tany)1 Type Merrill WI1Vol- — <br /> No- <br /> 0 D <br /> a c0 <br /> or <br /> z <br /> LL1 o <br /> 3 <br /> 14.Spri Handling instructions and Additional Information <br /> 15. GENERATOR'SfOFFEROR'S CERTIFICATION:I hereby declare that the contents of this ransignment are fully and accurately described above by the proper shipping name,and are classified,packaged. <br /> marked and labeledlplacarded,and are in all respects in proper condition for transport according to applicable interoalionaland national guarmsentril regulations.If export shipment and I am the Primary <br /> Exporter,I certify that the contents of Il consignment conform to the lens of the attached EPAAcknowledgment of Consent- <br /> I ce"that the vrasle minimization Statement idenBhed in 46 CFR 262.27{a}(N f am a large quantity generator)or(b)(AI am a small quantity generator)is ffice. <br /> Generatorsl0fferoYs Prnted,7yped Name Signature <br /> Month Day Year <br /> J 16 International Shipments <br /> ❑Import to U.S. Ex❑ port from U.S. Pon of eni <br /> z Transporter signature(for exports only) Date leaving U.S.: <br /> rY 17-Transporler Acknowledgment Of Receipt of Malemis <br /> LLI <br /> Transporter 1 PnnledfTyped Name Signature <br /> Monro Day Year <br /> O <br /> a - Signature <br /> zTransporter PrintedlTyped Name <br /> 4 Month Day Year <br /> K <br /> r <br /> 18 Discrepancy <br /> 18a.Discrepancy Indication Space ❑Cuantty C Tyti ❑Residue <br /> ❑PafUal Rejection ❑Foil Rejechon <br /> Manifest Reference Number <br /> 1Bb Alternate Facility{or Generator) US EPAIDNumber CZCID <br /> D <br /> J > O <br /> ca D <br /> u4.. Far.ly'9 Phone- Q <br /> 10 18e Srgnatura of Allemale Facdiry(or Generator) j <br /> Monty pay Year = <br /> 4 <br /> y ng syslams} v <br /> 19 Hazardou`,Waste Repan Management Memod Codes(i.e�.+tides for hazardous waste Ireabnent drsp3 sal.anti ret qiIN <br /> N 2 <br /> G t Q O <br /> r Or Opel <br /> L;BrtiflWbm of recoipt of hazardous materials covered by the manifest exoepl as-tied In Item <br /> cQ nand Facility Owns Signature O W <br /> 2r1 Dos 9 <br /> Wyped!Jame - Monty Day 1e-I Ip <br /> O_ _E O <br /> p� SPA Fara 8700 221ReY 12.171 PM �i00 are obsolete , OPYCID <br /> • •yu.: <br /> �' J <br />