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Form Apoved. OMB No. 20504039 <br />rtuabc pint vi tying. <br />UNIFORM HAZARDOUS <br />WASTE MANIFEST <br />1 Gemtaicf ID N`finter .. <br />2. Page 1 of 3 Emergency Response Pitons 4. Manifest Tracting Number <br />0 2 4 3 6 3 5 5 9 JJK <br />5. Generator's Name and Mailing Address Generator's Site Address (if sitieren1 than mating addressl <br />_ <br /> <br />.7, . <br /> <br />Generator's Phone 2 I <br />6 Transporter 1 Cattail,' Name U.S. EPA ID Number <br />Transpotter 2 Company Name U S. EPA ID Nornbet. <br />I <br />Deaignated Facirey Name and Site Address U S EPA ID Number <br />Factity's Phone - I ' . " - 7' ' <br />ga, 9t U.S. DOT Descrimon (inctuding Proper Shipping Nave. Hazard Gass. ID Number. 10, Containers r Total 12. Unit 13 Waate Codes <br />ard Padeng Grcup fil any; i No. Type atafitity AVVOi. <br />1. - .:R.7, I...,, <br />ire a w 1 7-c <br />, w <br />0 <br />2 . <br />3. <br />4 <br />14 Special Handling Instructions and Additiorail Infomietion <br />,'.." • • ''." :7 '' 7 . _ : <br />15. GENERATORISIOFFEROR'S CERTIF)CATION! I hereby dedare that the crintents of the consignment ere Italy and accurate)/ descnbed above by rhe proper shipong name, are are dassteeo, packaged. <br />miviced and tabeledblaardeci. ard are in alt respems in proper condition lor transport according to applicable international and nabore governmental replabons 6 expo shipment and I am Me Prvntvy <br />Exporter. I certify that the contents of this ccrisigninent conform to the terms of Me attached EPAAcitnowledgrrent of Consent <br />I oertfy that the waste mrentration statement identified in 40 CFR 262.27100 I am a large!oariaty generator) or It) 011 am a small guanbty generator) is true <br />Signature Month Day Year <br />Generatcepitafferces Prited/Typed Name ":_&., I.8 I2k Ik 113 <br />-. <br />,t3"Inlarrtalional Shipments El ri <br />import to U.S. Export from U.S. Port ot entry/eel <br />Transpotter signature (for exports onty; Date leaving U.S. DESIGNATED FACILITY !TRANSPORTER I Transponer Acimmeedgmen1 of Rome'. of Wanes <br />Tra Ion e• 1 Pm:tett/Typed Name <br />C/—..-. <br />Monte Day Year <br />6, Oil -Y-11 i •e-Z <br />I Sianabiri <br />e OM* or 1 J <br />rTlar,SPOrlef 2 Printecryped Name Signature Not* Day Year <br />I I I I <br />Discrepancy <br />18a Discrepancy indcabon Saco <br />Affr-t-vd <br />El Warmly Type El ReSIdtle JPedal Rejection El Full Rejection <br />Lyis .a t . 134. Manifest Reference Number. <br />8b. mate Facility (or 1 t1.S EPA ID Number <br />Facidy's Phone. I <br />.18c. Signature al Aa8r11821Fatty tor Generator') lacnth Day Year <br />1 I <br />Hazardous Report Management Method Codes 0.e.. codes for hazardous Valle treatment disposal. and recycling systems) <br />1 1. <br />U i \ <br />2 3. 4 <br />Designated Facility Owner cur Operator Derek:aeon of receipt of hazardous matenals covered by the manliest as S fern I <br />7 Primed/Th liti .y.). ctz)ifiz1/4..... Iare %F <br />— <br />Month <br />tic 1 1---1 2 <br />EPA Form 87003Z2 (Rev712-171 Premous edgonetrirobitMe