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� ,�3oagaa490 5c, PPrD Io/�oJaoi <br /> Please pnnl or NK.(Form designed for use on eYte(I e•p•tco,ty{ vnler) FormAwovod OMB No.20b0.0039 <br /> UNIFORM HAZARDOUS I (weraelr 1u Number 2.Page 101 3. Response Pltarte e.YaNkst Traddrg Nur>mer <br /> WASTE MANIFEST co D 00 91 Ll 6� 9 g�ti 83 �3`� FLE <br /> cenMuxs Hama M redress mr�sea zu�tass 1 d lfuti rrra8rq addrvssy <br /> �J C N] b e C) —'aS <br /> t>xnCraWz PhanA Tt a - C�r C S3 7 7 Su $6SI <br /> ac A�'°yHOfbof-6' GoV (onmc�f-�S�f��c�S sac o313da� p <br /> S. <br /> D r � <br /> 7 Transporter 2 Cemgaay Name U S EPA iQ Itkmbef <br /> E l7osr4 Fop Name one 5��Adf-'a:acc- • LG7 U.S.EPA to Nber <br /> Dr-500 t.c) T l Q ao t 11 D U,C, m <br /> 13..1.+-f�ov�► 11 a� �e1j 3 CA D980��7��?6 <br /> F,a�'SFT i )-76a-Gaco <br /> ga. 9b U.S.DOT Description(including Roper Stomping Name.Hazard Class,0INturber. 10.Containers 11.To" 12 Unit 13 Waste Codes <br /> HM and P-ldng Croup(deny)) No Type Quantity wuVof <br /> Q -JO(,Ico tiJ. 0- S . CA(-,SC-)C, CAam Cm ZO Y <br /> C-A <br /> 2 A P <br /> �81 <br /> 3 <br /> 4 <br /> 15 GENERATOR'SWFFEROR'S CERTIFICATION: I hereby declare that the oonrents of tha consigrerrent are tuey and accur-a y dasrnbod abovo by lfw pt"p r sh <br /> are <br /> marked and labeledlplararded.and in al respects in proper condition for mn�, x� I� ary <br /> lransparl eCcortArtg b applicable internatiunal and national governmental re[pIL11i7r3 li expxrt sftgment w and I am Ina Pnvir rery <br /> Exporter,I certify that the conlents of fl is consignment conform to dv terms of the attached EPAAcknowledgment of Consent <br /> 1 certify Ihat the waste mtninm Wn statement identified in 40 CFR 262.27(s)(A 1 am a[no gtantily VRntr,)-o)or(bl t8 I am a small quantity gone w is true <br /> rlr.dt s< s n+ Narr.t, <br /> � 16 Inkrnalronal SNwNnu - <br /> ❑Import to U.S. Li Export from U.S. Port of en .hem <br /> T" tier i Iwe Ix a An,Only) laav i] <br /> 17 Transporter AcimmoedgrrerrlofRmoaMalerials <br /> LU <br /> ora,VoW s <br /> a Uos � asp � � a28 ,a <br /> a tea's oner rypW Nam, — remonth D8ry Yaw <br /> 18 Discrepancy — v <br /> 1Sa Discrepancy bdiratiort Space ❑ Quan* ❑Type <br /> LJ Residue ❑partial Rejection El Full Rejection <br /> _ f an tat Ite yew oo Nwr t r <br /> IUa Mernate Wity(or Generator) U S EPA ID Number <br /> 1 <br /> V <br /> LL r,1-74hl PFgnO <br /> 1F_Srrnaturo of pitemai.TZI,for Geaa,w,r} M:mt` Day Y'%ar <br /> a <br /> x <br /> rn 19 Hazardous Waste R - <br /> rn spat Management Method Codes i i c..oodes for hazardous treatment,disposal,aril rt:s dkV sp*rns) <br /> q <br /> 20 Designated Fanlity Dweror Opa+alcr CCotHication of receipt of hazardous matarials covered by Oro maridesi except as noted in Item 1&a <br /> i�• coo { , Srg' ),Sonar <br /> .l.C.�) �! e►� <br /> EPA Faam 87r1t3.22(Rev 3-05) Previous edr0tx s are ot.0!ero DESIG ATED FACILITY TO DESTINATION STATE(IF REQUIRED) <br />