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+► ^r-LMU f r(ONIC IIv1AGr- 61tNERATC)R 101111=111111H <br /> Form Approved,OMB No.2050.0039 <br /> r Please print or type. <br /> i.Gonarator lO Number 2.Page 1 of a.Emergency Response Phone 4.ManifestTracidng Number ��� <br /> UNIFORM HAZARDOUS 2 001794.498 <br /> WASTE MANIFEST 14 <br /> 5.Generators Name and Matting Address Genera ors Site Address than mailing address) <br /> (If d tferenl <br /> YULMA GALVAN <br /> SAM <br /> F��C[iaOtII�lil <br /> SW BOM WAY <br /> T,NG`tYs Phone 377--?IIT <br /> G <br /> U.S.EPAID Number <br /> 8,Transporter Company Name <br /> N ? D Q S Q 6 3 13 6 4 <br /> V8( IABS�� U.8,EPAID Number <br /> 7.Transporter 2 Company Name <br /> T T T'LnM ffMjIt 72"W L''0�, DL 0 0 9 S 0 3 8 9 9 B <br /> 8,Designated Facillly Neme and Otte Address U.S,EPA ID0 Number <br /> V�9[yLIAH>ti�S�70fyI'iS <br /> 7�II�BA <br /> SA�IiC>'��1�.�QI-tQd9 <br /> I L D 0 9 8 b 4 2 +4 2 4 <br /> Facllily s Phone <br /> W U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Centelnars it.Total 12.Unit 13.Waste Codas <br /> ga. and packing Group(9 any)) No. Type Quantity WINaI. <br /> HM <br /> o x 1. � � RGA=P=W=TM%LQ, DOW 331 <br /> i p 43 P DON <br /> z 2. <br /> 3. <br /> 4, <br /> 14,SpeclalHandling Ins tnlctionsand Additional Information EL oxft"by + tarz <br /> — b <br /> 41d�ff��loomW) r IfllaWE '' BitQtl4l5 lQGG2769 <br /> ��b90RT <br /> J5. GENERATOR'SfOFFEROWS CERTIFICATION:I hereby declare thatthe contents of this coasfgnmentare fully and accutatelydescribed above by the propershipping name,and are classified,packaged, <br /> marked and labeled/placarded,and are in all respects In proper condition for transportaccording to applicable International and national governmental regulations,If export shipment and t am the Primary <br /> Exporter,I certify that the contents of this consignment conform to the terms of the attached EPAAdmowledgmenl of Consent. <br /> I certify that tine waste minimization statement Identified in 40 CFR 282.27(a)(d I am a large quantity generator)or(o)Of I am a small quantity generator)Is true. Mdhth, Day Year <br /> Gene tat ����tedlr�Name Signature . <br /> r 18.International Shipments r L ❑ rt gym U.S. Port of entry/exit: <br /> ❑ S.import to U. p° <br /> F- Dale leaving U.S.: <br /> Transporter signature(forexportsonly): <br /> W!17,Transporter Acknowledgment of Receipt of Materials Month pay Year <br /> LUTransporter 1 PdRedfTyped Name 5igna€ure <br /> AS M Signa Month ' Day Year <br /> Z Transporter PdnledffypedName <br /> 18,Discrepancy <br /> 18s.Discrepancy Indication Space ❑ Quantity ❑Type ❑Residue ❑ ❑Partial Reaction of Rejacdon <br /> Manifest Reference Number: <br /> U.S.EPAID Number <br /> lab.Alternate Facility or Generator) <br /> J <br /> W Facility s Phono: Month Day Year <br /> 0 18c,Signature of Aitemate Facility(or Generalor} <br /> 19,Hazardous Waste Report Management Method Codes(I.e.,Dories far hazardous was Uealmant,disposal,and recycling systems} 4 <br /> 1 HPO 2. <br /> 20,Designalod Facility owner or operator Certifaratlon of receipt of hazardous matelots covered byft manifest except as nded in Item tea onlh Day ear <br /> slgnelure ` ` I <br /> Pr nledlPyped Name F <br /> L �c K11, t Ly r� r S <br /> Ef A Farm 8700-22(Rev.12-�7) viou editions are ofasotete, DESI ATED FACILITY TO SPA'S e-MANIFEST SYSTEM <br />