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5 <br /> 91F a print of type.(Form desi fled for use on este(12-pitch)typewriter') Form Approved,OMB No.2050-0039 <br /> UNIFORM HAZARDOUS i.Generator ID Number 121.Page lof 3.Emargencyliesponseftie manifest-Tracking Number <br /> K <br /> WASTE MANIFEST A. t "i 00555,637 JJ <br /> 6.GeneraWs Name and Malting Address GenerahVifSlte Address Cil dilferent than mailing address) <br /> Gartaratoef,P <br /> li.Transporter I Company Name U.S.EPA ID Number <br /> '.T[anspartar 2 Company Name U.S.EPA 10 Number <br /> 8 Desfgna7ed Faaliry Name and Site Address U.S.EPA ID Number <br /> a <br /> W u S.DOT Desorption Rtctdhg Proper Shipping Nam,Hazard Class,IO Number, 10,Cantainats 11.Total 12.UnI 13.Waste coeoF <br /> Hjj and Packing Group(irarry)) No. Type Quantity WLNol. <br /> % <br /> Lu <br /> Lu <br /> 4 <br /> 14.Special Handling hishmdons and Additional Wormatitm <br /> 15. GENEPATOR'StOFFEROFVSCERTIFICATtON:I hemby decbre that the contents of this consignment are fully and awjmt*described above by the proper shipping name,W are classified,packaged, <br /> marked and labelediplecarded,end are in all respells In proper condition for transport according to applicable international and national governmental regulations.If export shipment and I am the Prtmary <br /> Exporter,I certify That M contents of this consignment conform to the terms of be attached FIRAAcknowledgment of Consent <br /> I certify That he waste minimization statement identified in 40 CFR 2132,27(a)(4 1 am a UuVo quentityWerator)or(b)('df am a small quantity generator)is true. <br /> Generatces(Offeroes Nfiteffyped Name Signature fMonth Day Year <br /> 2% <br /> it T�lrp"rt to U.S. El Evort fr..U.S. portirylexii: <br /> Tfansporter signature(for exports only): DOW leaving U.S.: <br /> JF 17.Transporter Acknowledgment of Receipt of MateriSs <br /> Trans 5or I PdnWyped Name Signature Month Day Year <br /> CL <br /> U) A <br /> Z Transporter 2 Rinledtlypect Name S[grialiffe Month Day Year <br /> 18.Discrepancy <br /> 480.Discrepancy Indication Spare civantfty ❑Type ❑Residue F-1 Partial ked. ❑Full Rj..U. <br /> Manifest Rakrance Number. <br /> 18b.Alternate Faellity(or Generator) U.S.EPA 10 Number <br /> FacilitysPhone: <br /> 18c.Signature of Atemato Facility(or Generator) Month Day Year <br /> 19.Hazardous Waste Report Management Method Codes(I.e.,codes for hazardous waste trealn ant cEsposal,and recycling systems) <br /> 2. 3. 4. <br /> 26.Designated Facility Owner or Operator:Cedificalkm of roouipt of'tautdoas*Werlals covered by the manifest:except as rood in ftem 18a <br /> p1wedAyped Name j StBna ra Month Day Year <br /> % <br /> EPA Form 87GG-22(Rev.3-05) Previous editions are obsolete. <br /> TRANSPORTER'S COPY <br />