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. Pleasen(or Form proved,OMB No.2050-0039 <br /> pd <br /> { UNIFORM HAZARDOUS 1.Generator ID Number 2, gpa 1 of 3,Emergency Response Phone en t Trashing am r R� <br /> WASTE MANIFEST Z VES <br /> 5,Generator's Name and Mailing Address Ge re s rase(H d-ftront than mailing address) <br /> 7'"NAGIliLVAN <br /> PW!�C>}S Nl11C�8 <br /> S tVw WAY <br /> +tea Ir�� <br /> O.TranaporlarlCompanyNaWl U.S.EPA ID Number <br /> 7,TFansporter 2 Company Name U.S.EPA ID Number <br /> r <br /> B.Designated FadiHy Name and 3tte Address U.S.EPA ID Number <br /> V130UAPdZ'!HICUPWA[.9OLU17ON& <br /> LLC. <br /> 170 W.FMOr 111171M <br /> Paoli &Phone: AU"CA 917 <br /> ga, 9b.U.S.DOT Description(tnduding Proper Shlppfag Name.Hazard Class,ID Number, 10,Cartafnars 11,Total 12.Unti 13.Waste Codes <br /> HM and Paoking Group Of any)) No. Type Quantlty WfJUd, <br /> to <br /> x U0149.WffM EMDW=4 PMM n==Pgl=/A BLIC D003 I1QQf3 ACID ei=111i111%gTANEEM 5,1 f• <br /> it <br /> s 1 D F .66 P M01 791 <br /> PERACISM A.M.5.H% 1 ID F so P Dw 331 <br /> X 3. �WAtilS H�7W�lSs a II D= _ <br /> I n F 10 <br /> #1 lP Ia'1 <br /> 4' UKIM%WAMPOPMM ACM WI HWr IM TW DDD <br /> 10 IIf w LBM T80 lMbl�ACID IW MMIL!�III <br /> ! D F i►0 P 7lil <br /> 1 .S WerldHng Irretnresone andAddilksrr tniamaibn * QpPI <br /> F t�tan itt d b fits glrll 13)S ��t /an��?�A; <br /> W!J �11� 9��'1'i�4 <br /> t <br /> 15, GENERATMWSIOFFEROR'S CERTIFICATION:I hereby declare Bratthe ooatents of thts consignment are 010;and a ocuratetydascribed above by the proper shipping name,arca are ctassfBad,packaged, <br /> marked and labeledfplacerded,end are In di respects In proper oondMm for transport aceording to applicable IntemeWnsland national govemmentai regulations.If export shipment and I am the Primary <br /> Exporter,I cxsrtifythet to oonients of this owislgnment conform to the terms of Bre attached EPAAdcnowledgraent of Consent. <br /> I certify that the waste minlmtration statement Identified In 40 CFR 26227(a)(H 1 am a large quantityganats!W)or(b)([t am a small quantity generator)Is true. <br /> neratoeofferora PrntedRyped Name Slgnatu MonOr Dey Year <br /> Ge <br /> i <br /> 16.IntamaVond Sh1pmBftt8 ❑import to U.S, ❑EWA from U.S. Port of entrylextt: <br /> Transporter signature(tor exports onE: Data leaving U.S.: <br /> 17.TrensporterAoknowledgmant of Racelpt of MaW* <br /> Trans 1 PrirrtedllypedNam� , Signature L th Day <br /> Ye <br /> ransporter 2 PrintedlTyped Name S{gna Month Day Year <br /> s'. <br /> -ae4t�r Ll <br /> 18,Dtacrspancy <br /> 1 Be.Discrepancy Indloallon Space ❑ Quantity 1:1 Type ❑Reeklue ❑Partial Re}ectian ❑Full Roc*. <br /> Manifest Reference Number. <br /> 1Bb,Alternate Fadlity(or Generator) U.S.EPA ID Number <br /> h;- d <br /> FadlWs Phone: Month Day Year <br /> 18c.Slpnahrre ofWtemeta Facility Generator) <br /> 1 <br /> 19.Hazardous Waste Repot Management Method Codes(Is„oodes for hazardous waste treabnent,disposal,and regding systema) <br /> Tfl714 <br /> 3. H1q1 <br /> t. <br /> 20,Designated Facility 6rrtrei or Operator Cersflcafion of raoelpt of ous materais oovered by ft manliest ax Item 18a <br /> nth <br /> nature Day18( <br /> Yeat <br /> �: n Nama lQ1Ij <br /> a <br /> EPA Foran 87th-22(Rev.12. 7) Prevloua ed1 Ions ar�gbspldta.' DESIGNATED FA LI 0 s e-MA IFEST SYSTEM <br />