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flow s�p Lln�or�pe FormApproved OMBWOOW0039 <br /> FUNWORM HiV.ARLj)1O):U8 1,Goner ID Number 2.Page I of 3.Emergency Response Phone —_ 4,MaulT,7R—Tracking Number <br /> T <br /> WASTE MANIFF$T t_ j C <br /> 72 _J <br /> 5.Gcjfieraior!sNrpo and Mq1lingArld[es, Generator's Site Address(If different than mailing address) <br /> n <br /> GonerMar's Mow a' -j <br /> 6,Tronsporter I Coiripreiy Nanno U.S,EPA 10 Numther <br /> Wf-' En J I C A D 0 '11 'D <br /> 7.1 Fn p <br /> 'rier 2 ce IF <br /> Jo IZ <br /> are U.S.EPA614um�,ar <br /> AN <br /> Dptiqruiwl Facility Name and Site Address <br /> U.S.EPA 10 Numbor <br /> e <br /> 'ar. ,p <br /> III <br /> C <br /> 0 91 Z' F) 4 14 G <br /> FFF Art t'. <br /> gar. qh. DOTOo9crIplion(Inducting Proper Shipping Name,Hazard Class,10 Number, 10.containers I I Total 12.Unit <br /> III,A and Packing Group(if any)) No. Type Quantity W001, 13,Waste Codes <br /> UN 1 AO,V ST F Q,-iid� <br /> '111nc <br /> a n ii on and Additional 1.n.tomi ics� <br /> 'V <br /> J <br /> Sow zz-Z-4/3 <br /> Z)K.� <br /> F'E`N_LR�T_O_FVS16FFEROR'$—CERIIFICATION;I hereby—declare that the_contents of thisconalgriniont are fully and accurately described Above by the proper shipping name,ani aro cinsgilled,packaged, <br /> "I'skud mid letaled/plecarded,and are In 811 respects In proper condition for transport according to applicable international and national q emTrital regulations.If export shipment and I am ins POitiaiy <br /> P'xljort'l,I("Onify that lho coldrinh of thbwnslgnrnont conform(a the terms oftho attached EPAAcknow1prigmentofConse <br /> I cul iffy that the waste intrimization statement Identified In 40 CFR 262 27(a)(if I am a large quantity g fa <br /> small antilAneotor)Is true. <br /> Name Signature <br /> L r4 ror-, <br /> _t 1ta <br /> Internationallff,41pZ ' <br /> ❑ , a <br /> to q. ❑Expert from U.S. Port ol'anirq.,xil: <br /> y1e, <br /> Ttii;ispoi lei,Ignaluia(for exports only): Date leaving U.S,: <br /> 17.Tmosporle(Aftowledifinent of Receipt o(Materials <br /> Signature- Day— Yoor <br /> 01:2. <br /> Name Transporter 2 Printed/typed Name Signature Month Day Yew <br /> __ I e <br /> 14.01'cyepancy <br /> I its,Dkr.repancy Indication Space. <br /> Quantity ❑19PL El Residue Partial Rejection Full Rejection <br /> Manifest Reference NurOor: <br /> 18b.Altanuda Facility(nr Generator) <br /> U.S,EPA ID Nu;L�r <br /> Piwiiny's Phow <br /> Signalure of Meiners FedRy(or Geneiai.,)' "7'i Day rYO ii r <br /> I_wX1_1dr1to_WZ_t(1'keporl_ManAgoment MOW—Godes codes for hazardous waste treatment,disposal,and recycling systems) <br /> 2.. <br /> 37iiomnaIcd Holloy ower or OPOIFAW:Certification of receipt of hazenlous nuitedrilq covered by the manifest except as noted In Ito 100 <br /> Signature Month—Day Year <br /> Alma Vacio <br /> 17-171A Form 11700.22(Rev,12.17) Previous edilion,,;are obsolete, DT"IGNAT0.0 lrAGILITYTO Ri�'S T <br />