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Blease or .pe. Form.t4 ' t trir use On Mite(12 pitch)IYP d ) -9C PPW 10/10/20)7.. Form Ap ved.OMB Na 2�50�0�9 <br /> UMFORM YIAZ g 1_Genara�r ID Number 2.Page 1 of 3.Emergent y Response Phone 4.Manifest <br /> WASTE[!RAMRST amt,°r �4 <br /> 923 FL <br /> D ra rle ss ' d'erent than mai ngaddress) <br /> 25� <br /> y/Moll 2526WWifthheonSam <br /> M203 <br /> 1 U.S.VIA ID.NUMber <br /> Trarr poter2 I <br /> U.S. PA ID Number , <br /> .Designated �' ama' gite'pddreas <br /> U.S.'SPA ID Number <br /> CAD9B'0675276. <br /> 4a: 9b l�.:S.OPT Dem( 'r+g NaRrte;Haadrd O"s,IU Number, 10:Containers <br /> HM and P 1g t�up faay)) 11.Total.. 12,Unit 13.West Codes <br /> No: Type Quantity Wt.1Yol. <br /> :. DS. <br /> � <br /> A <br /> and atiort <br /> 15. tYOR'8iY 1 try deter 1t�t ft=arJrrglgPxr1 are#ally nd accurately described above b the <br /> Mftd and labekedlplacard0d,and are in atl respects inp opt for Y r ,and a ssr7fetl G�Caged <br /> apart aoonrding to eppfi 8W�9mational aMnalonal governmental iations.ff e) s) t 1 am ft Pnplary <br /> Y iflet th9 err dstaf.dais cart smr. g t�am dt 15PAAcl0owedgment of Consent. <br /> & in 401 CM*�t(�, f arin 8 quentity generator)or(b)(if I am a small quantity generator)is true:. 3 <br /> n57-- <br /> Import <br /> ore <br /> k.J Import to U.S. from U.S: of en !exit: <br /> ? s <br /> 13.Tterup W of Rec*of tmfaterisis Date favi U.S.: <br /> MW ay War <br /> Tdw <br /> ,rotate .. <br /> El Quantity'. Type ❑Residue ❑Partial Rejection FNN <br /> t"t Re�LMion <br /> ffib Allemete Fa41ti ManifestReferenee N mber- <br /> 1Yt r+ 3 U.S:EPA IDNwdw <br /> g'None <br /> 18c. tt-Mtitreofx9;;ta arG®rreratot) MoMGI Day Yearn <br /> 19.Ffmwdws w"L.f�qw Afaine9ement M&,Dd Coles O-e.,was for hmrdous waste keatmenl:disposal,and recycling systems) <br /> Ha 3: 4. <br /> 20. F Orme o 0Perator:Certifloatiot of recx;ipt of h motet els covered by the manifest except as noted in ItWAN s 1 <br /> ` <br /> :Signature oath y YAW <br /> EPA F ev. l et9rllons are obsoWle IGNITED F <br /> t M� �� �e fvllr add M O DES <br /> . . �# the <br />