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,; � °• t (Forn1 dessgred for Use an elite f 12-pits. -ewriter) -0rn1 Approved.01.113 Nc 5 <br /> I G eratcr ID r . 4.ManestTraCkln�NumbcxFrUNfFOFM HAZARDOUS <br /> WASTE MANIFEST JJ <br /> 5 Gelmato ;Name arc Mailing{Address Generators Site Address(d different than mailing address) <br /> ,�Icr rine- <br /> ;., ,;:orier';:ompanv Name U,S.CFA lG Number <br /> ;'.1ran. kir 2 Company Name U.S.EPA ID Number <br /> r ;P ^d Sire q trirsss U.S.EPA ID Number <br /> P'io;tr <br /> U.—- D 3 C oto,o ciuding Proper Shipping Name,Hazard ClassiD Number, 'r.Containers 1,Tota! 12_Unit <br /> Hr1 orad t ck.� 9<, it a.y), 13.waste Codes <br /> No. Type Quantity wt.tVcnl. <br /> Q <br /> W <br /> z <br /> W <br /> C7 <br /> EIV <br /> k,--, <br /> 4 ; <br /> E.NVIR tNME IAL HEA00 <br /> td Special Handling Instructions aryl Additional Infomlatton - <br /> 5. GENERATOR'5IOFFEROR'S CERTIFICATION: I hereby declare that the cont"of this consignment are fully and accurately described above by the proper shipping came:and are class f ed,pacttaged, <br /> markc-i and labefedblacarded,and are in all respects in proper rendition for transport according to applicable international and national governmental regulations,if export shipment and I am the Primary <br /> Exporter,i certify Irt';he contents of this consignment conform to the terms of the attached EPA Acknowledgment of Consent. <br /> I certify that the waste ntz,nirrizAtion statement identified in 40 CFR 262.27(a)(it I am a Targe quantity generator)or(b)(If I am a small quantity generator)is true. <br /> GHrreraiUts-UYfie z'.nnted'Typad Name Signature f0,041 it! Day Year <br /> .j 15 l ',matonattbrnenbs <br /> f- import to U.S. Export from U.S Port of entrylexil: <br /> ansGorie srgnatare(f r expors nnlyt: Date leaving U.S.: <br /> 1 .T anspartar A area kjment of Receipt of klatenals <br /> fransh W.1leJi i p tia!rre Signature Month Day ea <br /> 0 ; <br /> KL <br /> dTransporter 2 Pnnte ed Name Signature Month Day 's?ar <br /> IA D,rrcpancy, <br /> ?Sa.Discrepancy incilcatrn Space i Ocanfity ❑Ty; ❑Residue J Partial Rejection )cull Re ectm, <br /> Manifest Reference Number <br /> 18b nitemate F�(or{�sneratnr U.S.EPA ID Number <br /> r acuity's Phone: <br /> w 18c.Signa'ure of Alternate Facility(or Generator) Monk Dar Y-1: <br /> d <br /> C1 <br /> 19.Hszardous kT{a;?e ReaCrt Ntanargentent hieihal Cotler{ie codas for hazardous waste treatment,dispose{,arta racyding sy5temsj <br /> W <br /> 20 Cresignated Facility Owner or Operator Carfifa,atlon of receipt of hazardous materials covered by the manifest except as wed in Item 18a <br /> Typed Name Signature Mona, Day. Yea.. <br /> EPA(xrn 8-100-22(Rev.3-05) Previous editions are obsolete. <br /> KSIGNATED FACILITY TO GENERA r ,' <br />