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5V ,HTP# 23041-:6524i iiilli li it iii l l li iii i <br /> 0 0 7 2 7 5 1 4 3 S K S <br /> Please print or type Form Approved OMB No 2050-0039 <br /> UNIFORM HAZARDOUS 1 1 Generator ID Number 2.Page�of 4 Manifest Tracking Number <br /> WASTE MANIF 1007275143 SKS <br /> Genera!ors Nameir'+Maif:,3 Genpiator's Site Address(if diffarera than maiiing address) <br /> 7 <br /> Geftta!Vs Phone. <br /> 1)ITA7U,S EPA ID Number <br /> �7 IV-,TFMC TIBC <br /> 7 Transporter 2 Company Name U.S EPA ID Number <br /> 8 Designated Fac-Illity Name and Site Address "'LEPN HARBORS VTE U.S EPA ID Number <br /> N Tgr-'f- <br /> AL,la�J4 4 <br /> Facility's Phone <br /> 98 9b U.S.DOT DescrIption{including Proper Shipping Name.Hazard Dass.ID Number. itl Cantarrers 11 Total 12 Uiil: 13.Waste codes <br /> HM and Packing Group(if any)) N3 Type Quantity VA-IVol <br /> P 10 ' RCI 2-DO <br /> N RA HAZARDOUS WA5�E SCILIP, <br /> '--ijRBPNT`3' CONTAMINATED WTT€.. 01L) <br /> L <br /> 1-7 <br /> 14.Special Handling Instructions and Addltoat tnfDrmaMn 7.-f <br /> ass :9N C si F 9-17 60 DA S !T F I- t <br /> 4- <br /> t r,o r t P il t ri, -4 d 0 r,r I b 7�.t I f F' a dd 3 t i "I'F; <br /> 15 GENERATOWSWFEROWS CERTIFICATION- I hereby declare that the ocritarlts of this consignment are fully and accurately described above by[he proper shipping name,and are classified,packaged, <br /> rrorkeiI and labetediplacarded.and are in all respects in proper wndOon V transport according to al:iphcabie nlernahonal and natural govemmental regulations.If export shipment and 1 am the Pnrraay <br /> Exporter,I clarty that the mnteritis of this consignment Go*rm to the terms of the attached EPAAgknowledgmerll of Consent. <br /> I certify that the waste rninimizalf9in statement identified in 40 CFR 262 27(a)(if I am a large quanirly genenalof}or(b)lif I an a generate,')is true. <br /> Generatoesx4mrs Printed Signature Month Day Year <br /> *11A I �s I r I ZZ 17-0 <br /> fo.Intemationai ShipmentEwrt' <br /> impart to U.S ❑ M U.S. Porto ell <br /> -j <br /> Transporter sigrialire(for exports only), Date eawg U S. <br /> UIx 17_ rter Ackilowlec9mew of Rec�il of Materials <br /> j <br /> 1.- 1 Pnje6lry'nen Na," Signature Month Day Year <br /> Z Transporter 2 PrirtedlTypid Name Signa re Month Day Year <br /> 9 0) 1 Zs- 10 <br /> Ia.Discrepancy <br /> 18a.Discrepancy Indication Space ❑ QuanOj ❑Tvpe 1 Residue 0 Parfia!Rejection El Full Rejection <br /> Manifest Reference Number, <br /> >- 180 Allcrnaje Facility(or Generator) U.S EPA.ID Number <br /> Fadisty's Poore. <br /> 18e.Signature of Altemale Facility(or Generator} Month Dav Year <br /> 12 Hazardous Vvasl,%R irtillVianagoinerTl Method Gooey(I e.(.W.es for hazarcous waste ireamm jrs-pv& and recycling systems} <br /> LLI 2 <br /> 0 T <br /> 29. O4 icer Or IN.Cerlificakn of r <br /> fe- ei hazardous materials covered by the manifest Pxcepl note ja <br /> -P <br /> Pnnted'ryVCj Name -)�mr <br /> EPA Form 8700-22(Rev. f2- ,_, „revious edition etc DESIGNATED FACILITY TO EPA's e-MANIFEST SYSTEM <br />