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Form Approved.SIMa No 2 Plea <br /> q.Manifest Tracking Number 050-p039 <br /> Emergency ResP°rise Phone J J K <br /> — Page 1°f 9. mailin9 address) <br /> 2 r(diHerent than <br /> Generators Site Address <br /> 1 <br /> ?;ease print or type- t C''rats ID Nine <br /> �r,nt7S <br /> 3r- Utz 9TE WREST- U.S.EPA ID Number <br /> n-iyty�Name <br /> 5 C aid <br /> Mar9 <br /> U.S.EPA ID Number <br /> C";,ft Prprp ny Name U.S.EPA ID Number <br /> :,?ComPa^Y Name <br /> 11 �I 12.Unit 13.Waste Codes <br /> 10.Containere Clur� Wt.Nol. <br /> ' TYPe - <br /> ,! <br /> Haza�Class,ID Number, No. 9 <br /> 1 <br /> 7a <br /> HIA a- <br /> al Information <br /> 15 GENERATOR'SIOFFEROR'S CERTIFICATION:I hereby declare that the contents of this consignment are fully and accurately described above by lh r -per shipping name,and classified,packaged, <br /> ma ked and labeledrplwarded,and are in all respects in proper condition for transport according to applicable international and national governmental r. ations.If export shipment d I am the Primary <br /> Exporter I certify thatlhe eortiiiinfs of this consignment conform to the terms of the attached EPA Acknowledgment of Consent. <br /> I certify that the waste minimization statement identified in 40 CFR 262.27(a)(f I am a large quantity generator)or(b)(ill am a small quantity generator rrue. <br /> vGenerator`srOAerorsPnnted/TypedN—C,,) '&'r Signature -jith Day Year <br /> J 16InlemaDonalShipments <br /> z Import to U.S. El Export from U.S. Port of entry kit: <br /> Transporter signature(tor exports only): Date leaving U.S.: <br /> W 11Iranspate•AckrawiedgmentofReceiptofMatenals <br /> Transporter 1 PdntedlTyped Name <br /> rp t^ r , J Signature nth Day Year <br /> Q <br /> z Transporter2Pnnfed/rypedName 23 <br /> FSigna ure r <br /> onth Day Year <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space <br /> ❑Quantity <br /> El Type El Residue <br /> ❑Partial Rejection ❑Full Rejection <br /> 18b.A temafe Facility(or Generator) <br /> J <br /> Manifest Reference Number: <br /> WtQ Facility's Phone: U.S.EPq ID Number <br /> 18c.Signature of Altema(e Facility(or Gene ator) <br /> a <br /> z <br /> 0 119.Hazardous Waste Report Management Method Codes <br /> (i.e.,codes for hazardous waste treatment, Month Day Year <br /> 2. disposal,and re <br /> 2 n cycling systems) <br /> 0 Oesi <br /> g ated Facilrty Owner or C 3' <br /> Printed/fypedName DeratorCerGficaGono/r I <br /> receipt of hazardous materials covered 8700 b 4 <br /> EPA Form y the manifest except a , <br /> -22(Rev.12-17)Previous editions are obsolete, s noted in Item <br /> m 18a <br /> Month Day Year <br />