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Please print or type,(Form designed for use on e'ite(1' Pitch)ty «Iter.) Form Approved.ON,18 No.2050-0039 <br /> ;UNIFORM HAZARDOUS I Generates ID Numb-r 2 Page 1 of 3.Emergency Response Phone 4.Manifest Tracking Number i <br /> 'i (( r)I�4/�f�to 1 <br /> WASTE MANIFEST l)0 3 a. I �. / 0 JJ K <br /> Generators Name and Ma'ling Address i Generato s Site Address(d d:8erent than mai"ng address) <br /> it <br /> 70 <br /> Lei Phot11 11 <br /> 6.TTrlransporrtt�er 1 Company��N-ante „sem ; U.S.EPA ID Number <br /> A <br /> 7 Transporter 2 Company Name U.S.EPA ID Number <br /> 8.Des:naled Faorily Name and Site Address U.S.EPA ID Number <br /> 1. <br /> I-P /r-1 />� a p, <br /> FaoBt's Phone b _> c�/' `/1 <br /> ga. 9b U.S.DOT Description(indud ng Proper Shipp ng Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit 13.Waste Codes <br /> HLI and Pack;ng Group(if any)) No. Type Ou ntxy Will Not. <br /> O at.r I ),) �) l 1 ) l�(J06 l�5 <br /> z 2. <br /> W <br /> c� <br /> 3. <br /> 4. <br /> Special Handing Instructions and Additional Information <br /> 76 <br /> i5. GEN ERATOR'SlOFFEROR'S CERTIFICATION:I hereby declare that the contents of INS consignment are fully and accurately described above by the proper shipping name,ant are classified,packaged. <br /> marked and labe!edrplacarded,and are in all respects in proper condition for transport according to applicable internaborwl and national governmental regulations.If export shipment and I am the Primary <br /> Exporter.I cenily,that the contents of this consgnment conform to the terms of the attached EPAAcknwledgment of Consent <br /> 1 certify that the wasle m alization statement identified in 40 CFR 262.27(a)(if I am a large quantity generator)or(b)lift am a small quantity generator)is true. <br /> GeneraloesrOfferor's Prmtedrryped Name Signature Month Day Year <br /> ri ` !� ilv l'u.rr� J .'-l•J.1; ��/'r .(� f. ;i � '/ �' [1 <br /> -r 16.nternatbnalShipmenl <br /> 1— t6, ❑Import to U.S. El Export from U.S. Port of infryJexil: <br /> Transporter signature tr r exports only): Date leaving U.S.: <br /> Ii Tran;ponerAdnonledgmentufReceplofhlateriats <br /> Ix Transporter i' intedrf)'ped Naar a- Signature Month Day Year <br /> O <br /> zTr6bsp—or er 2 Plonfildrryped Name SgnatuPe"" - A!onlh Day Year <br /> 18 Discrepancy <br /> lea Discreparuy Ind'caeon Spaces ❑ 1 <br /> Quantity / �Type ❑Residue ❑PartialRTa)ecGon ❑Fu'I Reedion <br /> `Ilia /1r` ( ./(;, I!. ;%r./�J �lf}.'/fl L!h)�� lf�Q41 6° l.JllJlr I/ r• ;i' ,f ./r/j��/�// r, /l:'/', <br /> _ Manifest Reference Number. <br /> tab Al ewnale Fau dy for Generator) U.S.EPA ID Number <br /> J_ <br /> V <br /> u Fac Sty's Phone. <br /> W 18c.Signature of Aitemate Face ty(or Generator) Month Day Year <br /> Q <br /> Z <br /> 9 HazarJous Nate Report Alanagemenl f.lethod Codes(i.e.,codes for hazardous waste ueatmenl,disposal,and recycl,ng systems) <br /> //// 2 3 4. <br /> 20 De:;gnaled Fac;ay O..ner or Operator Cert-f catlon of receipt of hazardous materials covered by the manifest eYsepl as noted in Item 18,1 <br /> Pr t�&d' d N me Signalurelt/ / t / Month Day Year <br /> EPA Form00-22'(Rev.3.051 P�ditionsare obsolete. U[SIGATED •ACIL.ITY'10 GLNFRA-1011 <br /> N <br />