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<br /> Please print or We. ' Farm Approved.0M No.20%0039
<br /> UNIFfJRM HAZARDOUS; 1.Generator ID Number (response Phone 14.Manifest Tracking Number
<br /> WAS7EMANIFEST: 21
<br /> 9"99=
<br /> CpL@0m346;.;,;:;>,. .:, .., ,. .::M•:' :E"i ': :.
<br /> 675 ` 1 rs�'ri ;eass "".0, 74808'5 JJK
<br /> 5.Generator's Name and MaingAddress
<br /> . a Sire Address(d di8erant than mailing address)
<br /> tAaESA:�GIq�•;IF,��DBA�ADESA�}GOLDEN;,GTE�;��:;: .-. .
<br /> GYOA
<br /> ZAAS3UGeheralves
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<br /> U.S.EPA ID.yuinber..
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<br /> T. ransponer 2 Company Name
<br /> 'U.S.EPA ID Number
<br /> B.Designated Faddlity Nerve and Site Address '�.3c� •::;,•:. ,
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<br /> 1"a, gb.U.S:DOT:Desr�iptiori(in'etud(ng ompar.Sh(pping Nerve,Hazard Class,ID Number. . to.Containers
<br /> RM ;arid Pepldng:Grorip pf ariy)) 11.Total 12 Unit
<br /> No. Type Quengly WLftL ?3.Waste Callas
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<br /> ; '74.Special Handling Insirifcgons andAddl9onal.l '• `f•,�.-H- -
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<br /> ' • 15.`.GENEI#ATOR'S)OFFEROR'S C 71FICA N.:I heieliy declare that the cerile'Ms of Uds.'efl -
<br /> marked antl iabeisd/p
<br /> ,:•: des'hell above.b thi*`Oi6. I rre iarit are eiassffied;'pary {etl".
<br /> . .... rudgriinent are Nil'end:axuratel .
<br /> lacarded,andaielnallres ,.5.: ::...•,•._.,., .. Y P..:P� .,Pp�!g...p!?,'.. _ ckag.,..,._
<br /> Pacts iri prpper cogilNiuii foRraesporl aizording appiicebh lntemationalan na net govemtnenlaa regutaiiorra.if export stdpment aril I srrtpe'Primary'
<br /> Exports,;l,irlly tlat AecoritenLs uf.lhle conslgnmeiit aorifoim bo the terms of the.attached EPAAduiuwledgm@nt of Conserv! "
<br /> i ::•_'I cerOfy that Ihepraste mintmiia(ton staleinent iderr9fled in 40 CfQ 292 27(a)(d I am a krge,gdangty. e. a
<br /> Iafar'sl s PrinledlTyped Na «(b) t anQy generator)is true.
<br /> �A,� �Mon ;°�AsY:� °:Yearn•:
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<br /> ❑Export from U.S. Port of enbylexfL
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<br /> (for cuff Date leWhOU.S.:
<br /> '�i;17_iransporferAdvdgmeritafRece(ptpfMatedals;.': + ���.
<br /> Transporter l Pontedf ed
<br /> :f= Signature M
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<br /> z Transporter2Printed/fypedName . _ .'�".`' �:�:`'' .
<br /> . ;Signature '::,Marithh .`:r Year
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<br /> 16.Discrepancy
<br /> i9a:Discrepancy lndloation Space
<br /> Quantity T e
<br /> YP ❑ResMue ❑Partial ReJecOon 0 Full Rejection
<br /> 19b.Attemate Fadh'ty(or Generator) Manifest Reference Number i
<br /> r U,S.EPA.ID Number
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<br /> �a- Facility's Phone:
<br /> W'18c.Signature ofAliemata Facility(or Generator)
<br /> a . Day Ywr
<br /> 19.Hazardous Waste Report Management Melhod Codes(i,e.,codes for hazardous waste Intetment,disposal,and reeycgng systems)
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<br /> ... 2
<br /> 20.Designated F rdity owner or Operator Cer#G �n of receipt of hazardous matelots covered by the rnanflestexeept as • in item 199
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<br /> dnle!t/T : w na •Mon ay Year
<br /> :PA Form 87 22(Rev.12-17) Previous'ediiionsare obsolete. DESIGNATED FACILITY TO EPAAMA61FEST SYSTEM
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