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Please print o%'!y�iilP'.. '.'.'WnrllftWid.ONE No.2050-0039 <br /> L Genesi IDNumbar 2Past l of 3.Emergency Response Phone 4.Manifests <br /> UNIFORM HAZARDOUS ((ryryqq ] <br /> WASTE MANIFEST , ') 4 €+001892: 3"[at Ul.� ( J 358 FLE <br /> 5.Detractors Name end Malting Arc.... Generators Site Address(it dilennt than mulling addrese) <br /> H81fieY IrPP1YbBl n•,.r. <br /> Generator,Phone ..'al 'J 10 <br /> s.Traoaporler l Company Name US EPA to Numbar <br /> '..,:hors FnvirnntnentalSorvicxs Inc <br /> 7.mareponer 2 Company Name U.S.EPA I0 Number <br /> 8.Designated Fa llty Name and Siteoddeses tl s.EPA to Number <br /> aeonflarioorsquitlr <br /> iiG00 Nmffi Antus Rua d <br /> FlAr,Tarn dello.UTA4079 <br /> go as US DOT Desantlon(Inciutlmg Proper Shipping Name,Hezae mass,ID Number, 10.Carry me 11.Tool 12.Unit 13.Waste Codes <br /> HM and Pri Group(tory)) No, Type Ouentiry WLNoI. <br /> a I1147 fit,1,WA TE MFOICINF.IIg1110,101 MDS_ <br /> X IMELPF!.ALANHLORAMRUt.!LI.C,.i.PG I! f1aiIlAPon) 013 (:F <br /> z 2. <br /> ar IIN.L 851.WAS)E MEOI1,'INE.1101i F081C.Nr) r'. d-T LTF 0000 <br /> X fMFIN'URY).111.PG III <br /> 3. <br /> IIN'1784,1111. RATTFRIFS,Il FIIA FI <br /> x nrl <br /> 4. <br /> I'AlIPPIE4,ONY,SFAI 170, 1x S.(A4RAWNE CIATTERIF't7 ;l0 i OF <br /> 14,Spatial Harding Intenders and Militional Informalon <br /> 1 CI4395360 Lvg;a L5.L 13 YS5 <br /> 2 .CN5182611 EMr:a'151 yl <br /> 3.CII122A iia ERG#154 ill <br /> d . er if., IF, Wei ,, .otor,...... ,., _ - . t lrtm•t rm urs=n rum• <br /> 15. GENERATOR'SIOFFEROR'9CERTIFICATION: Ihereby papers Net Ne contents of this consignment are fully and accurately dascrl0ad above by lha proper ffilpping name.aN are clatmed portaged <br /> marked and labaled/placarded,and are In all respeele in random condition for tianeponaeprding to applicable Inlernatlonalend national governmental regulations.II axpar Nrtomentanb I am re Phmary <br /> E%podah I prtity that the expects of the consignment contain to the terms of the agetreb EPAAcknowledgmenl of Consent. <br /> I early,that the Wase mirlmizaten statement identified In 40 CFR 262.9(a)Mlamalarge quantity recreation)or gat UN am a small quenlo,"normal)is true. <br /> GanermOlDgenr'a Pdnteprapad Name Stgnaen , IAo-0 Day Year <br /> 16.Inlemalloml Shipments ❑Ira rte LLS. <br /> i— import Ll Expert tram U.S. Proofentrydetit <br /> ? Transpoher signature(for exports only): Data letting U.S: <br /> M 17.Tmnspner Acknowledgmentof Reptptof Maer6 <br /> K Trram anepl PdntetlRyped Name Sgnalme Month Day Year <br /> 0 —. <br /> Ul Fire III <br /> 4 Tronsporm2Prloetlrtypetl Name Signs'. — Mont Day ear <br /> K <br /> 1e.DtsmepanW <br /> 188.Decrepanry lndicatic"pake ❑ Cpanity 1:1 Type 1:1 Proper EJ Panel Roadron ❑Full Rejection <br /> Manifest Reference Number: <br /> 18b.Alernale Faldry(om Generaer) LLS.EPA 10 Number <br /> U <br /> u Fa ity'e Phone. <br /> w 181 Signature research,Facility(or Generator) 7nIM1 Day Year <br /> at <br /> Z <br /> N19.Hazallous Waste Roped Management Melpotl Codes(i.e.,ekes for hazardous wase healment,disposal,and recyGing systems) <br /> 0 1 4, <br /> 11040 1.1040 <br /> 20,Performed Facility owner cr Operner Certification of reealpmerhazzor us metedals peered by the manifest except as read In Item 18a <br /> Prigaid ed Name Signature Monty Day Year <br /> EPA Form 8]0622(Rev.iS17) Previous editions are obsotee. GENERATOR'S INITIAL COPY <br /> Clean Harbors ads the appopNdlt pern1115 for and Fell accept the N3iTe the generarnr Is a milaung. N1 01/177?0100Sr 111"'eV <br />