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<br />fmm Annrnvnrl. f1MR Nn. 9050.00.40
<br />EPA Farm 070022 (Rev. 12-17) Previoas editions are obsolete.
<br />OENPftATOR'S INITIAL, COPY
<br />UNIFORM HAZARDOUS: 1.GonoralorlD Number
<br />2. PaAotor
<br />3. Eynergen�y ResPonso Pho}lo ,
<br />4Manlydsihaching Numbor
<br />�WASTEtAANIFEST � L C,,T-IHt.i},t;'-.j�ij �
<br />I
<br />� .'^�`-^4 !f �
<br />�,btiW4� � r �,p4u,��,� ���
<br />5. Generaloys Name and MaU�Ag Addross,- GeneratoYs Sllo Addmss (il dlllereM titan mailing address}
<br />IP'Il li'Cd 13 dt.ysri'1(ia ti f;4dt:
<br />1 " 6 �. S:f 1.'l. I.'1''f+ `i I','ii :r.l � V; d, '.'.f'P'J;<? (`:
<br />Generator's Phono:
<br />4. Trensponor 1 Company Name � � Us. EPA 10 Number
<br />tr; a,P. � I IIni;I4i � PII sci%?I , , ,, �qr�.l :: , 7;u ,,�� y,,:;�:�,
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<br />7. Transpmler2 Company Nnmo U.S. EPA ID Numbor
<br />O, Designated Facility Namo and Sile Address � U.S.EPAID Number
<br />N;6f;,;{) t Ill;lsi ;((fit ff.4 r.l 12{' k;3;r:i cr..
<br />t z;'- ! r i 'J.V; hili r'.r, ,,,, ',1
<br />Facfily's Phono: ;11^; Yr'i `�•'i�i4
<br />ga,
<br />D6.0.S.U0T DescrlpUon(Inrluding Proper Shipping Namo, Hazard Class, ID Numbor,
<br />10. Conlelnera
<br />11.Tolel
<br />12. Unll
<br />HM
<br />and Packing Group (If any))
<br />QuanOfy
<br />WINoI.
<br />13. Waste Codes
<br />No.
<br />Typo
<br />w
<br />1tl .�lEtiP ti!It^-1C;r„Id, ,t ,I€' titrd�l'sE ,l -ltj t(i„
<br />lit,
<br />W
<br />2.
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<br />co
<br />3.
<br />d.
<br />14, Special Handling lnsWcgons end Additional lnlormaVon 7.
<br />7
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<br />�llr.. ,, Ir.•, -I! I::. It��:1ri1 I".F'(1'1,",r
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<br />15. OENERATGR'&lOFFERDR'S CERTIFICATION; (hereby declare Utal Ute tonlenlsol lUls wns'gementere lullyend accmalely described above by the plopor stripping name,aN aredassiUed, pockeged,
<br />marked end IabeleJlplacarded,ond are In alhospecls In proper condition for bansporl acwrding Io appilcoblo inlemationeland na0onel govornmenlal regulations. II export shipment end I am Uro Primary
<br />Exponet I cerUty lhallhe wntents of Ihls wnslgnment conform to the terms of the attached EPAheknordedgmenl or Consent.
<br />I cedify Thal Ute Waste minimization statement Identi0ed In 40 CFR 282,27(a) QI I am a large quanliy generator) or (b) QII am a small quantity generator) Is We,
<br />Generelofs1011eror's PdnledRyped Name Slgnalme Month Day Yeer
<br />. ,�
<br />,�
<br />t8.InlernaUonal Shipments
<br />❑ tmpod to Us, ❑ Expotl front U.S. Pon
<br />F
<br />of enlryloxll:
<br />?
<br />Trensponor slgnalure (for exports only): Delo leaving U.S.:
<br />w
<br />17. TranspoderAcknovrledgmanl or Receipt o(Maledals
<br />Transporter 1 PdntedlTyped Name t slgnalure ' t � hgnih Day Yoar
<br />Trenspoder2PrinledRyped Names Slgnelure� Mon1h� Day
<br />Year
<br />xr.
<br />16, Discrepancy � - '
<br />tOa. Discrepancy lndlwllon Space ❑ quentit f ❑Roslduo
<br />Type ❑Partial Refection ❑FUN
<br />y ReJecUon
<br />Manifest Relerenw Number.
<br />106. Nlernale FacUity (or Generelor) U.S.EPAID Number
<br />U
<br />Facility's Phone:
<br />16c. Signature olAllernale FaclGty (or Generales
<br />Month Pay Year
<br />¢�
<br />Z
<br />19. Hazardous Waste Repod M11arragemenl hleUtod Codes (Lo.,codes(or hazardous waste Uealntenl, disposal, and recycling systems)
<br />g
<br />1.
<br />2. 3.
<br />4.
<br />20.Deslgnaled Facility Ovmeror Operator. CorUgcallon of rewlpf o(hazardous materials wvered by the manliest except as nded In item t0a
<br />Pnnledllyped amo slgnalure PAonlh Day Year
<br />EPA Farm 070022 (Rev. 12-17) Previoas editions are obsolete.
<br />OENPftATOR'S INITIAL, COPY
<br />
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