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Bee®55-16 L 6TSC. 133663:12461 <br /> j 2332733 <br /> '•P(sdse 009t or type.(Porto tlesi nebfor use on elite(12-pitchy typewriter.) � 1 Form Approved.OMB No.2050-0039 <br /> :UNIFORmlIAZAR00U9 1.Generator ID Number 2.Page 1 of 3.Emergency Response Phone 14.Manifest Tracking Number' <br /> WASTE MANIFEST a (R77) R77-2fifillJ 000119324 DAT <br /> 5.Generator's Nameand Mailing Address Generdloes Site Address(if different than marling address) , <br /> Sumit Ro0fiR9 -2Omices Scott D¢Dfiva SNruices <br /> 705 IRdustrial.Part Drive 705 Yixlastrial Park Drive <br /> Generators Phone: ' <br /> 6.Transporter 1 Company Name U.S.EPA ID Number <br /> 7 <br /> *Ak7f-A <br /> 2 parry Name - U.S.EPA ID Number <br /> \ Et/ evV1C0 <br /> B.D igrated Facility Name and Si Address U.S. P ID Number <br /> 21ST cEgT y EGVIOR.'�tEt a Eimf6'iF17T U C.E VTA. LLC <br /> 2095 7MR,"DS DOICE FAST' <br /> Fadli s Phone: FYMJLFV. 94 ( <br /> 9a. 9b.U.S.DDT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Cantearem 11.Total 12.Dell <br /> HM and Packing Group(if any)). - - - No. Type Duantily, R9JVnl. 13.Waste Codes . <br /> 1' M-RCU XMIRMS LASTE, UODID MI-V I-ITEN 6 228 <br /> o _ ,' �® <br /> a z' (CT100 BASTE RJ= SUID, IGOR&OC, U.C.S. (T1TlMHO DWI p A701 Dole Fels <br /> X (WD=J,,LMEST0W 5.1 P511 03(13001=100LDS) G DH' g!QU P <br /> P <br /> 3. <br /> a` <br /> , <br /> 4. <br /> 14.Specht Handling Instructions and Additional Information <br /> f ' <br /> (1) 752190-00 - OILT IMTE9 (2) 252192-00 MUM HIND SaUfM, STILI <br /> 15. OFNERATOR'SIOFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignmea are fully and accurately descKbed more by the proper sNpping new,and are dassified,packaged <br /> marked and lateeledliplaanded,and are in all respects in propercondition farbanspon according to applicable intematlonaland natlonal governmental regulations.ttezporl shipment and am the Primary <br /> Exporter,I certify that the contents of this consignment conform to the tens of the attached EPA Adumidedgment of Consem <br /> 1 certify that the waste minimization statement identified in 40 CFR 262.27(a)(g I am a large quantity generator)or(b)(ill an,a small quantity generator)is true. <br /> GenemtarslOfiernes;PrimedRyped Name Sign Mont Day Year <br /> I + 163 163 <br /> 16.Intemational ends <br /> j'. :,' 0 import to U.S. ❑5rpon from U.S. an of enlryledt <br /> Z Transporter signature((oiexports <br /> on : - D leaving U. .: <br /> 17.TrereepoMrAdmMedgmantof PaoWs(Melerieb <br /> Tmm 1Prinled/Fy�d Na - - - SignaN Month Day Yea <br /> y wFr ; vr 4,A <br /> d7. Transporter 2 PretedRyped Name - S'q to Month Day Year <br /> Of L <br /> t1&Oieaepanry - _ <br /> 18s.Dlsompancy lndice"Space ❑ Quantity 1:1 Type ❑Residue ❑Partial Rejection ❑fuAFtejectim <br /> Manifest Reference Number <br /> l8b.Alemate Facility(or.0aarata) U.S.EPA ID Number <br /> V <br /> I FadNys Phone: <br /> Ej I&SgraWre of Alternate Facility(or Generator) - Month, Day Year <br /> Q _ <br /> 2 <br /> h19.Hazardous Waste Report Management Method Codes(i.e.,cades for haran oris veaste treathren4 disposal,and recfc"systema) <br /> M14-1 2. 14ig <br /> 20.Designated Facility Dimer or Opemscr.Geraftal isompt of hazardous materials covered by the mandest exapl as Ailed M more 1 <br /> 111 PrFteM Name Sigraane Month Dry Year <br /> EPA Forma(06722 ev.3-05) Previous editions are obsolete. <br /> MAD 11111?TED FACILITY TJD JUENERATOR STATE(IF REQUIRED) <br /> • 1 � 2016 <br /> 12348.0343 <br />