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Please print or type.(Form designed for use on elite(12-pitch)typewriter.) Farm Approved.OMB No.2050-0039 <br /> UNIFORM HAZARDOUS 1.Generator ID Number 2.Page 1 of 3.Emergency Response Phone 14.Manifest Tracking Number J J K <br /> WASTE MANIFEST 4- = yf i):3 : = 3 `7 I, I,316 Ji': 9 r.-510172 <br /> 5.Generator's Name and Mailing Address Genera rs Saw Address(f different than mallkhg address) <br /> Generamrs Phone: <br /> "o.Transporter 1 Company Name US.EPAfO Number <br /> T.Transporter 2 Company Name U.S.EPA ID Number <br /> 8.Designated Facilly Name and Site Address U.S.EPA ID Number <br /> 98. 96•U.S.DOT Description(Including Proper Shipping Name.Hazard Class,ID Number, 10.Containers 11,Total 12,Unit 13.Waste Codes <br /> tiM and Packing Group Cf any)) No. Type Quaniry. wuvb. <br /> 134 <br /> 2. <br /> LL7 <br /> I C7 I <br /> 3. <br /> ' I <br /> 4. <br /> y [ <br /> t 14.SpecO h3adling Inslructiwis and Additional Information r <br /> ii�{� N <br /> - :L: :'.\•..i....In {'.L rpt'--.»�AiY:-:` ',. i'.r'�ll:y f P�J ll�IM'4 <br /> 15. GENERATOR`SfOFFEROR'S CERTIFiCAnON: t hereby declare that the contents of this emstgnmentare fully and amnately desrtlbed above by Ire proper shipping name,and are classified,packaged, <br /> marked and labaledlptararded,and are in all respeos In{roper condlbn for transport acro ding to applicable Intemallonal and national governmental regulations.Iexpori shipment and I am the Primary <br /> Exporter,I certify that the can[ents of this consignment wntorm n the terms of the attached FPAAduw AedgAwt of Consent <br /> I sadly that the waste rnirrmization slatement identified in 40 CFR 262.2T(R)(If I am a Marge quantity garwator)or(b)(0I am a small quantity gerwralar)is true. <br /> GenaretorsWer&s PrintedlTyped Name Signature Month Day Year <br /> r '18 inteinatiaral Shipments ❑Exportfr.U.S. Port of en' leAt- <br /> }'-- �import to U.S-' ay <br /> z Transporter signature(for exports only): Date leaving U.S.: <br /> 17.TransporlerAdmovAedgmentofReceipt ofMabwlals <br /> Fransporter"edlTyped Name f Signature Month Day Year <br /> CL <br /> s J' f t ' <br /> Ll <br /> aTransptater2PAM VP YYarrfe Sigrd re Month tray Year <br /> 18.Discrepancy <br /> 18a.Discrepancy Endlcalan Space ❑ Quantity ❑Type ❑Residue ❑1'artiaE Rejection ❑Full Rejection <br /> Manifest Referarhoe NtEydmr <br /> I Bb.Alternate Facility(or Generator) / U.S.EPA ID Nwrgfer <br /> V <br /> Facility's Phone. <br /> LL, 18e.Signature of Altemale Faulity(or Generator) MonOry Year <br /> z <br /> y J- <br /> 19.Hazardous waste Report Management Method Codas(i.e..code:for hazardous waste treatment,disposal.and recycling systems) j <br /> 93 1. 2 3. 4• 1! <br /> 20.Designated FaQlry Owrher or Operator.Certiti anon of receipt of hazardokis matedNs covered by the manifest e>sept as rho[ad in Item 18a <br /> Pkinl�dlTyped Name Signature Month Day Yaw <br /> EPA Form 870Q 22(Rev.305) Ptevtrxrseditions ar9 hihsolela. TRANSPORTER'S COPY <br /> x <br /> ' 4 <br />