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-Please print dP tyke, y. Form Approved.OMB No.2050-0039
<br /> UNIFORM`HAZARDbUS 1.Generator ID Number 2,Page 1 of 3.Emergency Response Phone 4,Manifest Tracking Number kk
<br /> WASTE.f�hAN►FEST rt,, r�; ,r � C F
<br /> p �, . s •c j
<br /> 5.Generator's Name and Mailing Address :Generator's Site Address(If different than mailing address)
<br /> X05 GANDY D'.A'N9�>ER DR,
<br /> Generator's Plion;
<br /> 6.Transporter 1 0a�`t�ame:' U.S.EPA ID Number
<br /> 1 c, 7.Transporter 2 Company Name U.S.EPA ID Number
<br /> ra_ r6 ��w:,,��,. �„rr �.,� =,r:�� n�aw�'•n , gip
<br /> 8.Designated Facility Name and S.IIe Address U.S.EPA ID Numbers
<br /> 46
<br /> �G3�W
<br /> Facility's Phone'
<br /> 9a, 9b.U.S,DOT Description(Including Proper Shipping Name,Hazard Class,ID Number, 10,Contalners 11,Total 12.Unit
<br /> HM and Packing Group(if any)) No, Type Quantity Wt.Nol. 13.Waste Codes
<br /> 1.
<br /> o t\rC. +f;kr,,R�hsA�'(�6�DOUS kk0,k u�.L10. 1D,L`;�"2OLWT,SIk-110�G4�� ikf 3 Dtin 10 IN G �
<br /> 0
<br /> 4. .
<br /> AUG 9 '2019
<br /> 14.Special Handlin `Ihstructions and Additional Information
<br /> GO
<br /> 8['&ERGEWdY,b0NTACT.-STEVE
<br /> 15. GENERATOR'SlOFFEROR'S CERTIFICATION::I hereby declare,lhat,the contents of this consignment a're fully and accurately described above,'by the proper shipping name,acid are classified,packaged,
<br /> Marked and la¢eledlplacatded,and,are;it all respects in properconditiop for transport according,to applicable l,nlernational and national govern ehtal regulations:if exporl•shipment and l am the Primary Ik
<br /> Exporter,I certify Ihatthe c mten(s of(his consignment conform to the terms of the attached EPAAcknowledgment of Cohsent;
<br /> ar e. uanlit enerator o b If I am a small u nt i�enerator Is.true,
<br /> h 7(a)(if l am a t.,
<br /> rile 9 „ Y 9 ,� 4 )( .,,. •. . q generator)I cdrn. that the waste minimization;slate/mentJdentifiied.in 40 CFR;262s2
<br /> Gener�rs/00 rs Pnnted[T ed Name 9 f� Month ,Day: Year.,
<br /> u IMpart to U S;( EX ortfrorn U S Porllof e t lex
<br /> Trans rnational Shipments � it:
<br /> 16 Inte p �n NY.
<br /> z
<br /> porle{'slgnaiuie(for expgris only)r'` Date le'avin'g U,S:,
<br /> oC 17 TransporierAcknowl4g'ment of Receipt of Materials
<br /> LU .Tia s otter dnted(f ped Name,/0; ' Signptur Month Day p Ye r
<br /> " .
<br /> ,-%14
<br /> Z Tran o
<br /> iter to/Typed Name ' Signature f Y ," Month,A a r Y r
<br /> 18:Discrepancy
<br /> 18a-PIs6tepane indl
<br /> y cation Space . -. •<_. - -.. .:. ,...___ �:-:_-- - . . . .-
<br /> 0 Qpa'ntity Type Residue Partial Rejection Full Rejebtio�
<br /> Manifest Reference Number:
<br /> 18b.Alternate Facility(or Generator). '. U.S.EPA ID Number
<br /> V.
<br /> L<1 Facility's Phone:
<br /> w 18c,.Sfgnpture ofAlternate Facility(or Generator). : Month Day Year
<br /> 18 HazardousWaste Report Managemeil M ( trealrner t,disposal anq recycl% ln8systems)
<br /> •,� f ethgd Codes I e;codes4brhazardous waste
<br /> LLI
<br /> 8,s; 4
<br /> 20.'DesignatedMMFacility Owrler or Operator.Certification of receiplof hazardous materials covered by the'man)fest exceptas holed In1tem•18a; A
<br /> Pdnted(Typed Name Signature Month Day Year
<br /> 8700-22(Fe-TI Previous editions are obsolete, �' 9�MATED TQC@�� T® ENE -' ,,:
<br /> EPA Form ( ) Prev
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