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" "Ie SY.- olldt nJrs�V'�{i !"b.Y+M_-FaCptK Please print print or type,(Form designed for use on elite(12-pitch)typewriter) Form Approved,OMB No.2050-0039
<br /> UNIFORM HAZARDOUS 1.Generator ID Number a r,, 'xB r,, . 2.Page 1 of 3.Emerg racy esponse Phone 4.Manifest TrackingANurn ar (Q+.�(��++
<br /> UNIFORM
<br /> MANIFEST I �eT.Ik3 . r tA,.r� 9. 9 3;{.f Hl'_�k4,tf$ 17�t") '"• " r^ 67K1�
<br /> WASTE521216
<br /> 5.Gamester's Name and Mailing Address - Generator's Site Address(if different than mailing address)
<br /> C aP, I •iT " to T!N:! 0 r drr,,:s :rw
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<br /> Generator's Phone
<br /> I Tra, Oft Co Party Ngume U.S.EPA ID Number
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<br /> 7.Transporter 2 Company Name - U,S,EPA ID Number
<br /> B.Designated Facility Name and Site Address -1 CPkYxi
<br /> O Rx'i°7pea t#~ITyI 94) •5 P7et - U.S.EPA IO Number
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<br /> `'ItpPLO',F',R,y D DAD
<br /> Facility's Phone:
<br /> ga 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11,Total 12.Unit
<br /> and Packing Group !f an 13.Waste Codes
<br /> HM 9 P( Y)) No, Type ` Ouanlily. WLNoI.
<br /> 1 qy p. I, + f d du riAZARK Sh WA13TF �Ck-"'i"o�3a'
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<br /> _ 14y.,Special Handling.IPsiruckonsand Add!flonal informationg7i:, s.��, rt.Q}n1 3075 ¢y'� 1} r8sa7 a�w � l
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<br /> 2 4 MiT y its RETE CY it 6(60-,to&.h a l Z i° I "s`"F b e
<br /> 4UTH ASi Lr .fF1'3-•FOR" VISI lS9 'Q1 pil V-l�&NSE°d9 231 tial RII-Lzs AIR �9' t.F'h`Rak'yr
<br /> 15 GENERATOR'SIOFFEROR'S.CERTIF[CATION: I hereby declare[hal the contents of this consignment are fully and accurately described above by the proper shipping name,and are closeted packaged
<br /> marked and Iabeledlplacarded;and are In all respects in proper condition for transport according to applicable International and national governmental regulations,If export shipment and I.am the Primary
<br /> Exporter)oddly that the contents of into consignment conform to the terms of the attached EPA Acknowledgment of Consent,
<br /> *, r,°edify that the waste minimization statement identified In 40 CFR 262.27(a)(if I am a large quantity generator)qr(b)(If I am a small quantity generator)Is true.
<br /> Gene to slOHOror's Printedlf ped Nape Signature ., p 7 Morgb Day Year,
<br /> V4 ✓' `�...+4•vi w.b Y e��,�✓ "°:D .d3 ✓A �J ffd i,:�4 Y
<br /> .i '16-International Shipments
<br /> �. ❑Import to U.S. LJ Export from U.S. Pod of entrylexit
<br /> z Transporter signature(far exports only): Date leaving U.S
<br /> W17 Tra✓mypoarterAcknowledgment ofReceipt of Materials �,,...•�«.
<br /> Trarfs +o,tpr''I Pgrinlel`dl ad Name Signature,✓ p ' p' , Month Day Year
<br /> �tl\ d p omh' y3 Year
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<br /> z Transporter 2 Prinfedfr'ed Nama_ Signature Months, Da Year
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<br /> 18.Discrepancy ,
<br /> Ann.Discrepancy lndlcatlon Space ❑ Quantity � Type Residue Pa �,xa) oFull Relecl! a
<br /> Manifest Reference Number:
<br /> 18b.Alternate Facility,(Or Generator) - U.S.EPA IO Number
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<br /> ra Facility's Phone: -
<br /> w 130.Signature of Alternate Facility(or Generator) T,,,, -„Q Month Day Year
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<br /> -N 19.Hazardous Waste Report Management Method Codes(I e.,codes for hazardous waste treatment,disposal,and recycling systems)
<br /> w 1 2. 4
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<br /> 120,Designated Facility Owner or Operator Cedifica[ion of receipt of hazardous materials covered by the manifest except as noted in Item zea ' 1
<br /> is 1 Piinledfryped Name - - Signature y Month Day Year
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<br /> EP Fo(,TOQ-22,�Rev 3-01),Pfevic us editions are obsolete. CD ES110i d�T'�D FACILITY T O GENERATOR
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