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Please prim or type- 110 76 0 a 8 5 3 9 4 5 6 S K S <br /> Ensporle� <br /> RM HAZARDOUS 1-Generator ID NUn ber 2.Aa�ge 1 0! 3.Emer envy Res onse Phone 4-Manifest Tracking umberForm oved,OMB No,205f]_p y <br /> TE MANfFEST t-{ilii ; r :r`:i i`t��xgIi—y.t��'--i 1 bo <br /> rator's Name and Mailing Address 008539056 S KS <br /> { �� Generator's Site Address{if diffailing address}1e c a'y S'F<S7cktfeTitI;L: ON liv416 Navy Or <br /> L:t�r's Phone:oa r 7 C mpY_' Lby;itil i f�f€ U.S.EPA ID Number <br /> jA,Ft�11111 1c"rnorte*2 Company Name <br /> H ? I-'kH'bURb I-I yjVL INTI U-S-EPA lD Number <br /> . esgnated Facility Name and Site Address LLII Hj4V'8UX`moi Lid W i Lid 111 i Lf Int U.S.EPA ID Number <br /> 1 i 6l L€4,,j 1 t.3hNN L S I€2LE 1 <br /> W1LMINUi€iii s L;H JO i44 <br /> Facility's Phone- <br /> 9a. 9b-U S.DDT Description(including Proper Shipping Name,Hazard Class,ID Number, <br /> HM and Packing Group(j!any)) 10Containers11-Total 12.Unit <br /> No. Type Quantity Rivol 13-Waste Codes <br /> ibLE L 1 UU l i1, N.U. ti. , <br /> oLOL€:HMEIMYLLYL;LUPE;,Nl"biL€�AkNE3, pOm <br /> N el`+ <br /> €,LAO)6Ui 1 1 bLL L i UU 10, F-'b i 1 1LLl <br /> 2 2. <br /> 3. <br /> 4. <br /> 14-Special Handling Instruclions and Additional Information <br /> ,;I-l ! (--)9C)aq()9 <br /> LM1--Hb .;1 t;y#8W0--4b8—E lbld—Ufl/SK/ 11,1—L iDtltraclt retaInecl by generator cOII agency autnr,rjt <br /> on zrlati,al tr Tt�11111iorter to a30 or bs gat a <br /> ll <br /> 15. GEIVERATpR'Slr7FFEROI'S(.9MFfCATIQN: 1 hereby declare that the contents of this cansignmeni are fully and axurately desaibed above b theUgnora r <br /> marked and labeledlplacarded,ond are in allransport Y proper shipping name,and are classified,packaged, <br /> Exporter,I certify that the contents of this contnmentJconform to the termsofthe attachedrEPA Acknowledgment of Consenttl national governmental regulations.if export shipment and am the Pr maty <br /> I certify that the 11 waste 11 mi11 nimixatFon statement identified in 40 GFR 262.27(a)(if I am a large quantity generator)or(b)(If I am a small quantity generator)is true. <br /> General11:, feror'11 s P 11 rintedfrype Name <br /> n 9 Signyre Mo�f} i�y Year <br /> —j 16.Int ationat Shipments ❑ <br /> Import to U.5- <br /> Transporter signature{for ❑Export from U.S- Port of entrylexit: <br /> exports only]: <br /> ir 17,Tr Porter,Acknowledgment of Receipt of Materials date leaving J,5.: <br /> T po r 1 Printedfry erne <br /> p Signalu Mh Day <br /> y Year <br /> aTransporter 2 rintedlTyped Name <br /> GC L Signature Month Day Year <br /> 18.Discrepancy Z;U <br /> 18a-Discrepancy Indication Space <br /> ❑ Quantity ❑Type ❑Residue <br /> ❑Partial Rejection ❑Full Rejection <br /> III 181b.Alternate Facility(or Generator) Manifest Referenda Number: <br /> r U.S.EPA ID Number <br /> U <br /> u Facility's Phone: <br /> N18c.Signature of Alternate Facility(or Generator] <br /> ZMonth Day Year <br /> 0 i9,Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling sysfemsl <br /> ui 1. <br /> H141 2 3, <br /> 20.Desicnated Facility Owner or Operatar:Certifca' of receipt of hazardous materials covered a manifest except as noted in Item 18a <br /> Printed Type m <br /> f Signature Month flay <br /> EPA Form 7d0-22( 1 -17) Previous edi roes are obsclet <br /> DE !GNAT!=O FACILITY TO EPA's 0-MANIFEST SY <br />