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Program: 000054190 Please phht or type destued for use on elite 12- itch ewriter ed. OMB No_ 2050.0039 (Form _
<br />1 ID Number 2 Page 1 of 3i, En,,,,,...._ UNIFORM HAZARDOUS
<br />WASTE MANIFEST .)
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<br />11 Geteuratc/$ Namr: erit I.' i • 7: rtddres)
<br />Genemw,sde A.r.„, ,,,,,,,,mn, th.,:a.:nganoo,:srp:a3chineg '1-'7 ResPonse Phone N2umbi 3. i 6 G B F
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<br />t 4-57 60 Ps-P— 4I As0- fis9 11'411\44 P 1 C)\---- 760 — („ o 1,
<br />Genc:ator's Phone
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<br />6 Trans oder a Company Name U S. PA ID Number
<br />\A, i l..c,Ar 1 ItO It \ ) 1\t,14-1 • 5 \f‘RaU k.C--e-,5 L-L-C----
<br />7 Transporter 2 Curepany Narett U.S EPA ID Number 4 GENERATOR ---------- Facile
<br />8 Designated Facility Name and Site Address U S EPA ID Number
<br />'a Phone
<br />Na.9b U.S DOT Description enctuding Proper Shipping Name, Hazard Class. ID Number. 10 Containers 11 Ti3131 12 Unit Code, um and Packing Group ef any)) Na Type Ocan1 7y Vit
<br />13 Waste
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<br />(-ir)) SciLy 0.4-5 4- D i cis 0-1 0 k ' °I
<br />1.1 Special Handling Instructions and Addrhonal Informer)°,
<br />GENERATOR'S/OFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately descnbed above by tne proper shipping name, and are classified. packaged,
<br />marked ard labeiediClaeoderl, and are in ail respects in proper corefifion for transport accorded to applicable intematfonal and national governmental regulations. If export shipment and I am the Pemary
<br />Eyperrer, I ,,,IIFy mat tha contents of this consignment orlon to eke terms of the attached EPA Acknowledgment of Consent_
<br />. , ,..iii i• i,. i.-.., , , i .., - , --dawn statement rdenufied in 40 CFR 262.27(a) (if lam a large quanUty generator) or lb) (di am a small quantity generator) is true.
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<br />14 50t4 1 n'\ I--_,,,,___._-_
<br />Month Day Year
<br />106' 1 Lq 24
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<br />Intern, El Import to it s El boort from U S Port of entry/exit.
<br />Transport,- exports only) Dale leaving U.S. ITR ANSPORTERI 17 Transporr, r at Receipt of titaten
<br />7 nsport P:ii 1 Se 6.4- 0 Month Day Year I I' \ I
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<br />l°iC I isf I 2/ Transporter 2 Per... Name Signature Month Day Year
<br />I I I. I 8 Discrepancy
<br />lea aK,epanyind:cawn space 111 0„antty 1N Type D Residue 111 Partial Rejection III Full RelecIton
<br />Manifest Reference Number
<br />I8b Aiternate NOW (or Generator) VS. EPA ID Number
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<br />< u- Famithfs Phone:
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<br />I 8c Signature of Alternate Faddy (or Generator)
<br />19 Hazardous Waste Repeat
<br />p4,,,,,gemee, method Codes (1 e oudes for hazardous waste treatment, disposal, and recycling grams)
<br />Month Day Year
<br />LLI cl 1
<br />operate, ceroa,ce
<br />2
<br />of receipt of hazardous matenals covered
<br />20 Descnated Faaay 0,,,,„r ,,,,
<br />by the manifest except as oiled in Item taa
<br />3
<br />PrIntedrimed Name &gnaw.,
<br />Month Day Year
<br />'I 22 (Rev. 3-05i Previous editions are obsolete
<br />DESIGNATED FACILITY TO DESTINATION STATE (IF REQUIRED)
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<br />CL o•-• Elena Manzo, RENS
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