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<br />UNIFONM HAZARDOUS t. Gene(a�a lO Number 2. Page Sol 3,�morgapcy Response Phone 4. n at a IG
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<br />WASTE MANIFEST <=
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<br />G.Genaatots Name and MallingAddress _t '! OBerelota SlleAddress ddiflerent than mallln address
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<br />Generalots Phone:
<br />G. Trenspoda t Campairy Nama U.S. EPAID Number
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<br />7. Trenspoder 2 Cnmpany Nema �
<br />U.S. EPA ID Numha
<br />B.�,pes�q��F�Ifyt�a��a,Q•���t�gdf��c. - U.S. EPA ID Number
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<br />Facility's Phone:SBf-<�r2-N`r.Sd
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<br />9b, U,S. DOT Dasuipgon (indudkg ProperShlpping Nama, HazeM Geas, ID Number,
<br />18. Containers
<br />11. Total
<br />52. Unit
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<br />amt Packing Group (d any))
<br />quantity
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<br />t3. Waste Codes
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<br />type
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<br />14. Spedel Handling InsWclions arMAddllbnal Information
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<br />1G. GENERATOR'SrGFFEROR'SCERTIFICATION: Iherehydedare that the contents of this rnnslgnmentare lullyaM accumtdy desalted abovo by the proper shipping name, amt aro dassified, packaged,
<br />marked ernl Iaheledlplacarded, erd are in ell respects In proper candlVon (ahansport eaadi:g la applgable InlemallonalerMnational gavermlremal regulatlons. ISexportshlpnenf and I am Ne Pdmary
<br />Expoder,lcedifytimt dla contents df Utis consigMmnt conform to the terms of the attached FPAAcknowledgmentofConsenf. -
<br />1 cenlly Thal the waste minlmlzaVon statement WenUMtl In 40 CfR 282.27(x) Qf I am a Targe quantity generelor) a (b) (gl em a smell quantity generela) is We.
<br />GeneralatsiGgeaN's PdnledRyped Name nate
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<br />18.Inlernelmnel Shipments <
<br />❑Unpotlio U.S. ❑Export
<br />� from U.S. Podorenlry(axil:
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<br />Transpaier signature Qaexports only): Date ledviny US.:
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<br />17.TrenspoderAcknowtedgmental Receipt orMaledels i�
<br />Transporter dnl ype .Np me '
<br />,1'I' / � Signature �'. i>' � Month � Day Year
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<br />Transpodar2PrinledRyped Neme
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<br />Day
<br />Year
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<br />18. Disceepancy
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<br />18a. Discrepancy lndicaVon Space � Ouanh'ty t_...1 Type ❑Residue ❑Partial Rejection ❑Full Rejection
<br />Manifosl Refaa+ce Number.
<br />58b.Nlernafe
<br />Fadtity (or Gonaalar) U.S. EPAID Numher
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<br />Fadlllyrs Phone:
<br />18a Signature olNlxmate Fadlity (xr Generator) � MonUl Day Year
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<br />19. Hazardous Waste Repod Management Malhod Codes (Lo., codes (a hazardous waste Treatment, d'�sposal, and raydk:g systems)
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<br />2. 3.
<br />4.
<br />28. Deglgreled Facility Owper a Operala: Cemllcatlon of receipt of hezartlous mal@rials cnveled by the manifest excop! as nded in Item 58e ;'
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<br />Pdnled/Typed Name Sgnalure Manlh Day Yxar
<br />EPA Form U7G0-221Rev. 12-t7t
<br />Previous editions are nhedete. ,......-..........�...._.., ___-.
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