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• + <br /> •Please Print or .(Form designed for use on die(12-pitch)tYpewritec) Form AWoved.OMB No.2050-0039 <br /> UNIFORM HAZARDOUS II'Generator Ib Number I2.Pegg 1 of I3.Emergency Response Pbm 4.Mar0hal Track g Number <br /> !I 11YASTEMANIFEST t,4100�1�a107 (,n�1a?J-CiFxl1 0041 598 FLE <br /> 5.Generators Name and Matting Mdress Generators Sita Address(it Offerenl than mad ngaddress) <br /> rep soy-,mcs? <br /> V101 Creroly a t.rt <br /> 4 tl W.V v <br /> ornilan• Maa ` 1:eigvr <br /> (:n r) 17, <br /> Generawa Phone: <br /> 6. ransporter 1 CDmparry Name U.S.EPA ID Number <br /> `t�riGya'1+_ �1er.ral:y:+Lasts _afutlar15 inc i41 fJ 5 4 0 0 t 1 n '� 1 <br /> 7.Transporter 2 Company Name U.S"EPAID Number <br /> Al' Ch--- 1twl UtaPoaM Int :`•A D 0 8 2 4 9 3 9 9 <br /> s.Desi natsdl Facility Name and Sile Address - Ent ironri ctntd!E"riterprise.4,Inc. U.S.EPA 10 Number <br /> f 5 t.�'I t-13�_; '_incirn ttl. G:-1 I5212 G H G O 8 3.3. 7 7 0 1 117 <br /> F Pharre: - <br /> go, 9b.U.S.DOT Descrobon(including Proper SNdppn9 Name,Hazard Class.tD Number, 10,CoMaineta 11,Total 12,Und 13.ftSIO Codes <br /> HM and P8ck 8 G-P(ranY)f No. Type Quantity WtAfd. <br /> ce 11Jid 19'if1.C'.F34i:.'H emi :.Ubrf!raTb!?,(P-xh(td :vec4ng 11. <br /> I/ ✓k. �ij��� 1111 f i' F 1)111111) r <br /> r 2. <br /> W <br /> 3 <br /> I 4 <br /> I i <br /> �'` •' i t�-�r�rl�r��� .�,J4gfU�0!•1 �r29S��1 <br /> 15. GENERA70WWFFERORB CERTIFICATION:1 Hereby declare that die contents of dais coes nmenl are fuly end acaaa"described above by ete proper stippi g name.and are clasulled.px*aged,. <br /> madcad and taWWpWMrded,aware in aA mspeds in proper salon Ear transport awartrog to appikable intdrrasionat and natiaal govenmrentai regutaWns.p export shipment and I am Bre Primary <br /> Exporkr.I certify tltiattha Car>oents Dt tllia sa►aignnrdnt mnbrm m the teats of the attached EPAAtknowl8dgmenlof Cwreatt <br /> I oe"that the waste m nnizaomn statement identified in 40 CFR 26227(a)(if 1 am a large quan*gac aa9ary,Qr(b)[d 1 am a-4 quantity ge is true. <br /> �r.19Typed Name <br /> 11 1 13 110 l <br /> F 16.International Shipments <br /> ❑ <br /> Z tmoto ❑Fw rom U.S. of enyedt <br /> Trans r re for orgy): fDa / <br /> lean U.S.: <br /> IT TwVaWArknowledgmtnt of REoeipt of MataEats Year <br /> Gar <br /> Transporter2 WypedName } 4pe �� Year <br /> iB.Disaepanq,..f s <br /> 18a.OWepM Indication Space ❑QuanwY ❑TYpe ❑Residue ❑N.0 Re)gcaiorr ❑RA Reiectfon <br /> Manifest Reference Number: <br /> 186.Alternate Facility(or Generator) U.S.EPA ID Number ' <br /> i <br /> ' LL Faa'I s Phone' I <br /> les.Signature of Altemate Featly(of Generator) Month Day •Year <br /> 19.Hazardous(Waste PAW Management Method CAdei('.e.,oodea fa hazardors waste vea rnem,disposal,end egang systems) <br /> 3. 4. ! <br /> 20.Designated FacBrty Owner a Operatw.CeAiSWw oI mWPt 01hazerdous materials oorefed Ery the rrrarifest except es noted in Ilam 18a .0, / <br /> yped N8 �/ r ttrre Year ` <br /> (lir I !f �'' t . r J .+Zr/LV�l�'.. 1- i 4 <br /> EPA -22(Rev, `33P5FOP tSeditions ar o3 ftj"00 400-07� 1 �...... •i if iL TLF DES tG '�'� r CfLJTYTO GEIS& OR <br /> [(JI <br />