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m o --I -g — Cn <br /> v � <br /> � � _ 0 �' <br /> � W � <br /> Z Arno � a' m <br /> w -4 <br /> CA) Oo � <br /> -n o -4 v <br /> o ` w <br /> � <br /> c <br /> Q- coC_ c ) <br /> 0 <br /> ghll NO. (0 3 c <br /> M hi <br /> = Ul ED <br /> iFNm � <br /> Rh0118 1 far Xa�an Wpti 12 Fonn d CPMB No L .�-. 4 <br /> hr 10 Nu�.r A71h;. 4 v 7 <br /> IFEsr UnN <br /> JJK W <br /> I, <br /> C) 07 CF)addr. <br /> del�'Ial 11 .Id,IIF.,.nl l4iea,..yr,y .ei <br /> CD <br /> —4 - Cb <br /> :wndalN�arty y s't'al-1 z <br /> s.rnlHno,l.r!CnmpAny Narrn ii.yg _ W <br /> .ucallZ s r V Xxme. O O CD <br /> an _ <br /> .mpAny Nam. - u I: N J CD <br /> r^ 0 <br /> FJT <br /> 1,19 AI NurnbM J W <br /> AOAGgn.[etl Fn[Aily Name.nd SNeAdllmss 0) L O <br /> 19 EPA In NuO <br /> I 1maw -4 T O C <br /> Far.Jll Fy,.ne' l: �..rel if /� <br /> Aa 9h U,5 nl Tllec��fA�`nn,urunin^Prq.r Shmlq Name, l:l•i.�.Il�ryCn <br /> e,HCn uni Lri_ ` <br /> HA1 aiJ Fm:�.id=rnur'I�1,niytl <br /> 1fl cN^alnar. 11 Trul 1Z tine " <br /> o 1 N., ryn. c..nnly m,va a w.Ar � J � O <br /> dent N T <br /> Lu <br /> ar O O <br /> CP — (1) 7 <br /> 00 <br /> , Q D <br /> W O <br /> u. L n <br /> C- O <br /> F 14_Spacial Hantlhrlg lnsrrodiams and Addiriortal lnfom,arinn W �' <br /> O <br /> CD <br /> yr - GENERAFOR'afDFFEROR'a CERFIFICAFION:I hereby declare tnat the contents of this rotrs ' <br /> CL <br /> manretl and labeletlrplacardad,and are in aH respects in pmp.rcondigon fprlran nac Illnmenlam lolly antl scoursfelydascribed abave6 the ro er she in arae, <br /> Ex t ,1 certry Ma Nre mmenla of this cnnsignmenl cnnmms to Iha terms a'Ins aadachad E AAckno fwladgmentof CanAse^td�lionel goyammenlaf g p If A n yrq am O <br /> 1�arnry Thal rhewaste minimization statement idenNNetl In 4p LFR 282.27(a}!if lam a la regulations.II export nhlpmenl and i am C,a Pnirriyy <br /> �erteralo/s;Onerer's CID <br /> Printedlryped Name rge quanlily generator)or Of Off am a small quantity generator)is 1'. 00 <br /> Signalpre 00 0) <br /> —a 7&,Inremalional5hi Month gay Yes M - <br /> i— pmeots O O. <br /> iranspodarsignefure(forexpons onlyJ❑Impm to u.g 00 <br /> ❑Export from 11.5. Portal enlryJexic M <br /> 17,iranspanerAckomWed pate leawng 11.5.; k C— <br /> gmenl o!Receipt of Materials <br /> transporter 1 PnnledrFyped Name O n <br /> � Signature � _— <br /> Q Tianspodar2 Pnnled/fyped Name M.1h pay Year <br /> 8ignawre N o <br /> } 18.Discrepancy ManthN pay yea <br /> 1f <br /> Ids Discrepancy indication Space ��---fr � W <br /> LJ QuanrgvO C))❑Type ❑Residue <br /> ❑Padial Refection (0 <br /> (or Gen (0 <br /> 18b.Aliemale FaclNiy erator) ❑Full Repolagl W <br /> Manifest Reference Number CJI C— <br /> C— <br /> US <br /> U.S.EPA 10 Number Cb <br /> LL Facility's Phone' W <br /> CA 7" <br /> BW Slgnatura ofAtlemAlto Fadlilq for Generator) O O <br /> i N) N <br /> Month L <br /> 19.Hazardous Wssle Repod Management Melhod God IS(l,s„codes for hazardous waste treatmem,disposal,antl recycling q0 <br /> sy5li Year OD <br /> LM <br /> O I 2. <br /> a <br /> s 4o <br /> ! ealgnaled Facility Owrrer w 6peratCr.Cenidcation orreceip!of hazardous malarrals covared by the manifest exce I a <br /> PrinledJl-yped Name J <br /> P 5 ndetl in item 16a W <br /> Signature � <br /> EPA Form 8709-22(Rev.3-65)Previous editionsare obsolete_ Mo nh O - <br /> cn C) <br /> (A -P, <br /> O <br /> GENERATOR'S INI (0 C- Q- <br /> $fULP t! r. "rXw S jubofls are dua.ne,.: (,J 0 <br /> � W W <br /> (Q T <br /> CD C_ N �13 <br /> L CD <br /> CJS COD <br /> C) OD <br /> O C) <br /> cJn W <br /> 00 <br />