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IINIlIIMH1 IN�ill�if <br /> Please n . <br /> n1 or type.(Form designed for use on elite(12-pitch) pewriler.) IIII�IIoil�� IN I III <br /> Form Approved.OMB No.2050-0039 <br /> UNIFORM HAZARDOUS 1 General 2 P <br /> ID Number age 1 cf 3 Emerq ncy Rrsptme Pww, st Tracl/ Number <br /> WASTE MANIFEST I 11 <br /> r1 I �`PLt�-�2fro—� 4.Manife4V 490WAS <br /> 5 Generator s Name and M,-at"AfteSs ,Pm ala s Site Address d different than.m¢dug afters) <br /> S'�•lticC�77�n. �i4 91'2oS— <br /> Gerleratof s Phone: <br /> ran Cotnpany Nwne US.EPA 10^ember <br /> 7 Transporter 2 GompPy Name U.S.EPA ID Number <br /> 89ledFackyName SileAddress U S.EPA ID Number <br /> .Tf7Q TT�v,Srvilm 6"�� <br /> F e s <br /> 93. 9b.U.S.DOT Description(wkiding Proper Shipping Name.Hazard Class,ID Number. 10 Conra rwis 11.Total 12 Unit <br /> HM and Pacl6 g Group(f any)) No Ty}x Quantity 13 Waste Codesy Wt N <br /> 4:Ace 1J,be s.Z�, ,o.S <br /> 96, <br /> 3 SS <br /> r <br /> a <br /> 14.Special Harding <br /> nstr sand Additional Information <br /> 15. GENERATOR'S70FFEROWS CERTIFICATM:1 hereby declare that the contents of hs consignment are fully and accuratelydescribed above by Ute proper shippng name.and are dwsihed.packaged, <br /> narked and laheledrplacarded,and are n all respects in proper condition for transport according to a-tumble ntematioml and national 9ovenmental regulations.t export shiprnert and I am the Primary <br /> Exporter.I cendy that the contents d dos consignment conform to the terms of the ahached EPAAcknowledgmem of Consent. <br /> I Certify Mat the waste minimization'Mcmed idemdied m 40 CFR 262.27(a)ff I am a large quantity generates (d I am a I w wky gewalorl is true <br /> ener r yppd Name Month Day Year <br /> 16.Inlentatiatal Shipments / <br /> Z ❑Import to U.S. ElFxpM• U.S. Port of entryfex4. -- <br /> Tranwei switire yar export-,rid : Date aving US <br /> L 17 Transporter Acknowledgment d Recco of Materials <br /> C9nanspoilet 1 Name r, a Year <br /> O t <br /> Y <br /> N <br /> 2Q 1rans WL4 2 Ported/Typed Name <br /> , LUC Udy Yefir <br /> 18 D rr epancy �f�7mal P, ((�ll <br /> J <br /> 18a Discrepancy kndtcation Spare Quantty {ype ElResidue F Parlerhon Lruff Relecn on <br /> Mantles[Reference Nunber: <br /> 18b.Allfudte Fwki for Generator) t15.EPA 10 Nunes <br /> U <br /> a <br /> � Fardi •s Phone <br /> OL <br /> 19c.Stgnalune cit Ahernate Fadily;or Gmeiator) <br /> w Mn to nay tva <br /> Q <br /> 2 <br /> htfn Ha?iYOus Waite Repan MariNcnurrtt NkYrad Coda,it e.,code;for 1lalardous wa�:ta tremnirm.rlmxisal.and recyckng sy<remy) <br /> C 1 1�� 2 <br /> 20.D:'.ig Idled Fdcdi nen.a Opcvator.Cenft-uoj of ,1ep;of hazardous :dle•:af;ctivrved by Inn..manifest exrept if rni.A n can 1.+a <br /> Pnatedfr d`lame Srr3rnah,rc Month Day Year <br /> FPA Fc1rm 8700-22(Rev 105 PreuK,us ednuns are Wsulme. DESIGN, EOX-C-1 ITY TO D STINA STATE (IF REQUIRED) <br />