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DIVISION _ <br /> 007756590SKS <br /> Please print or type, 9 5 Form Approved.OMB No.2050-0039 <br /> UNIFORM HAZAR000S 1.Generator lD Number ^.nc,(,.t7�7 2.Pagel of 3.�me� yR�.spotyseM, /. NasthaaMlgNwnber <br /> WASTE MANIFEST 007758590 SKS <br /> 5.GeneaNys Name and Matling0.ddressf GommWs SiNAddass(ddffe ltranmaigng oddrese) <br /> r.. N is ^ <br /> Genaretmis Phone: <br /> "Ort- T37-81 aC <br /> 8•hPtIPCW1at� y?E I r.:..TFM- 'Nr U.S.EPA ID Number TY^ a,a <br /> o 11.4 <br /> 7.Toonapoder(ah1 2 Company Name U.S.EPAID Number <br /> (:! 1,. _ir...Rn� r::'i�f rr•r rye(.. n"nl^ <br /> a.Desitim edFamlity Name and Si le Address (-I ( xq.)<<T._rnrrn rlr Pi;rr+-.r rt,.l ; DWI U.S.EPAIDNumber <br /> (.ic.t._-r(•?—r^IirJi I'On'7 r.p�. ,Fadi es Phone: <br /> pa, 9b.U.S.DDT Description(including Proper Shipping Name,Hazard(lass,ID Number, 10.Containem 11,Total 12.lhdi 73.Wesly Codas <br /> HM and Packhg Group(dmry)) No. Typo Quantity WtAV. <br /> s,30:7 tura�a�nnu: it8}cTF+ t7:- -Ti), h},n .� r-• nava: ,n1 <br /> G(:i ;T? <br /> �U <br /> z 2. <br /> 3. <br /> 4. <br /> 14. pecial Handling IrarudonsomAddiflowl Informaton TS1+:n,1 tiT .Y-fir;? } '�{t[cy��.({,' ' p <br /> FMF4r.,: ='1Ef,:T.:'--'�` ±r_:,.''rF:- r•::-41.�...{: :- P`:'.S r, hV _'.Fr:o :: , <br /> 16. GENERATOR'SIOFFERDR'SCERTIFICATIQN: I heahydedae that theeondents ofthis c 00ownant are fully and axumtelydesaihed above by the pmpershlppirg name,am affichmifiad,padraged, <br /> marked and Iahelednplecemed,and am Mil real in peopercondibbn kr transport axordirg to applicable mtematimaland national timmmmenlel regNedona.Nexpodshipmanl and I amthe Primary <br /> Exporter,I cerlilythat the mntenaolmie consignnamtadorm to the femme of be atmched EPAAdmoMedgmentofConsent. <br /> I xrlify that the Note minimimbon statement Identified in 40 CFR 26227(a)(dl am a large quan5ygenemtx)or(b)(til am a snatl quantity t>anemWr)Is We, <br /> Doneralon'slOgera/s Pdnlxafypep No Signafum+ Multi —Year <br /> 16.International hipments <br /> I— ❑Import to U.S. ❑Ezpod from U.S. Podcfenhylexib <br /> ? Transporter signalum(for molls only): Data leaving U.S.: <br /> K 17.TmmploderAdmoMedgmemof Ron*ofMalodals <br /> T r 1 Rinled/f(�e_d Name Svmem! Mondt Day Year <br /> A V�N� P� �� r� <br /> aospmter 2 medR Name <br /> YPed Signmum Month Day year <br /> s� <br /> V Z J <br /> I&Discrepancy <br /> too.Discrepancy Indication Space ❑ Quantity ❑Type ; <br /> ❑Residue ❑Padiel Refectim ❑Full Re)mdion <br /> Manifest Reference Number: <br /> 161h.Allemaa Fadmy,(or Generator) U.S.EPAID Number <br /> V <br /> xa•. Fadlltys Phoma: <br /> w 18c.SI9nahureofAfiemme FacrTdy(or CANK"tad Manlh Day Year <br /> G <br /> z <br /> 19.HmrdcpsWaste ReportManagemmal Method Codes(i.e..codas fMhaxardausnote,beatmemh ditpasal,and recyd'og systems) <br /> f� 1. 2. 3. 4. <br /> 20,Des a FedlityOwnormOpemtm:Centificaofrecelpt ofhamedous materials covered by the manlfesl except as rated in item IBe - <br /> Pdn Y BNm Mon Qa <br /> EPA Fon 6700-22(Rev.12•17�Previous editions are obsolete. DESIGNATED FACILITY TO EPA's a-MANIFEST SYSTEM <br />