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1111 IN III 11111 ILII ININ IIIII II III IN II 11111111111111101 <br /> Please nt ort (Form des ned for use on elite 112- rich)P Iter.) Form Appfovm OMB No,2050.0039 <br /> UNIFORM HAZARDOUS 1.Gerwrata D Number 2 Paige I( 3 Emergency Response Vtwxte 4.Mandest Track Number <br /> WASTE►RIFEST t lO0c�01 lir a -/zA1 44 4 4 A <br /> 5. ata'9 NSP and Ma Address Generator s Site Address eran than rr.AN address) <br /> �PCI7C'�7n� Gf 'T T R O <br /> Generators Phone: <br /> 6. r et Company Name U S.EPA ID Number <br /> � E'.�v`oma.•-�a.,.'t ,�c- �'il r�4� l/ <br /> 1.Traosporter 2 C Name US.EPA ID Number <br /> 8pe <br /> red; deryT1 <br /> Address U.S.EPA ID Number <br /> d� <br /> Fac 's Phorre' f TCS l \ O r7 O� <br /> 9a �PS DOT Description,mdudxtg Proper SFipplrg Name,Hazard Class,ID Ntmrber. 10.Cornalners 11,Total 12.UM13 Waste Codes <br /> HM ac"Group any Ne. Type Ouamlty WINot. <br /> o k 1 sTe ,t-arwk L'lkr.v►allS.9./, 6lil�gr0 <br /> � 2 ts� io�l.•�,.?,i l��s� <br /> I � � <br /> 4. <br /> 14.Special Handling Instructions and Add6onal Information <br /> 15 GENERATOWSIOFFEROWS CERTIFICATION: I hereby declare that the contents of this consgnmem are fuf y and acatatNy desalted bove by the proper shipping name,and are classified,packaged, <br /> marked and labeied0acarded,and are m al respects n proper condition for banspon accor <br /> Exporter,I catily that 1* aterMs d this can �9 to applicable Merrtalxx al aM t mal regulations It export shipment and I am the Primary <br /> sig ort carform to the terms of the anadted EPA AcknaMedgme tr <br /> Cely that the waste mF irrdzenon stater"dent fled m 40 CFR 262.27fa)(d I am a large quantity general I"Yam a i erata) ue. <br /> ame — e ay ear <br /> ,J 424n in <br /> LJ- 16.ka ❑krtpon a U S <br /> z Ex u s Pon d erttry7ex;t <br /> Tran er Ire fa a Date le U.S.. <br /> W 11 Transporter Acknowledgmentol Receipt of Luems <br /> N Tim 4ater 1 gnv a mom ay year <br /> QTranspo _gy e <br /> 18 Discrepancy <br /> 18a Di;crepaney Indication Space ❑Quantity ❑Type ❑Residue ❑Partial Refection ❑Full Rejection <br /> Manrfest Reference Nwrtber <br /> 18h Anerrule i ankty 6x Gerwratot US LPA i0 Numty <br /> J <br /> U <br /> Q <br /> "- <br /> Facility's Phone: <br /> w1k.S,gnaium of Alternate Facil y la:;nerarrx) <br /> F„ Month Day Year <br /> Q <br /> Z <br /> N19 Hazardous Wa,Ie RepM NLrnagerrtmm Method Cnrles Ir a cedes for hazardous wave heatment,disposal,and recycling systems) <br /> WO 1. 2 3 a <br /> 20 Designated f anility ei of OpfAlitr Cend atxm of ret pt of hazardous materials covered by the manlesl except as gen,18a <br /> 7r7,,—,,.' yp Skjratute 11a nh Day Yr-x <br /> FPA Fonu 8100-22(Rev.3-05) Previous m5, e obsolete. DESIGNATED FACILITY TO DESTIN STATE (IF REQUIRED) <br />