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Oct. 22. 20 12: 462. P.- <br />No, 1163 P. <br />..... <br />ase print or type. Form deeigned for we on elite 12- amlter. <br />, <br />UNIFORM HAZARDOUS 1.IJAM,10rlDNumber -. <br />2. Page101 <br />3, Emer enc Rey , <br />t Palo Poona <br />Form Approved <br />WASTE MANIFEST CA7000$BO.?J'FS <br />Y <br />.Maan�hoad a�ck'�n7g Number <br />S. Gp^Rf@ds NemB entl AhifngAddreea j <br />. 1 <br />tS7y...'i3'7 -9777 <br />SyF o e7 1 Q rv' <br />GeneraWla 9iNAddrws(N1eRerkaWnmelling <br />addrege) <br />;;t::.�� a�f.axk:� T)sinn+e;r- <br />?9Y'P rAgrclr 73e'ii.-re. <br />A,F.h. ea: I,tuVr1 !irejf <br />iT"k: 4. rr11, AoN f1,i7{1Pa <br />911:34:.1 CIA 932015 <br />Gen iia Ph <br />or acre. 14Cs 7dkf... 44earli . <br />6. Transporter I Cornmeal Name <br />'rNnel.d>ai, «1.. 8r^coyvalc & atswrk I:eMx. . <br />A Transporter Cooll Name r <br />C <br />a. De; - ad Fadllry Name and silegtldrese Y <br />" a `4 T'a�n7,ssrFy (594eaR$q, M4f). <br />'^tuhwloyOtt, 1,1I P... Ott Dae'Ilq kin, lP'll TyyyN 578 <br />FaCHII 'c Phone: S119sh-P;9O-90 3' .. <br />$e. 6b. t1$. DOT Desorption tindW►p ProperShlpping Name, Hazard Clem, ID Number, <br />HM ad Pecking Gmup(Ifany)) <br />f. rYrrr>...t3l.TiC.A 1lepraarpimes i7tek#,a $erl.d.si ([Ix..1;Y <br />isb:r,4xherat, (seNari,,ti) <br />U.S. EPA ID Number <br />IV. VIA Xtl""'re 111 12. 1 <br />No. TYpe Quaintly ` INUVol. 1s. <br />14. $pedal HeMling lnalN[Ebns 11111,pddid AI In <br />8�.�3f115 <br />i,13A. to @Ea.'r141iaicilla; gear Appx'apdteldp pra>t:e!.ce Ea.irq+ Y'j;a7Ebdn P_$ <br />''.'I n: iiaa�.. �6,'.. biT?:>'t�, �Z„i,'y'3 rJ}e� .eii 55: 16siMkEaonp eek) 1lViyasSltpNlila+ <br />15. GENERAL 1!11 0FFOROR'8 c91TI11I4ATI10111: 111111; edIII ttel8te cadenls of all, cons 111 1: 1, fid and actumlety deernbed above Ifie m rMii <br />marked and labaledlpl6carded, and am In all reapa�ys In Propercondidon(Or INFE t pa ty � p Pe pP Pama,erdered <br />Exporter, Icadify(hat lhaoodenlsofwa cotmlgnmentomdormlothefarmsel the diach EPAAcxnal wlHedgmmiltt of coomen-I national govemmer” mgulallons. If Ill shipment and <br />.. I coil dreg the waste mhlmlyatlon statement Identified in 40 GFR Yd2�7(e)(If l am a large qumtlrygenemlora dl amaemNl ue <br />Genal\ Dderoys PdnledRyped Nama ) mi( 9 rtNygenemlor)Is tore. <br />r . <br />16. IMetnalionel $hlpnente - <br />❑ImponmU.S. ❑Expon eal us. Pon of enbylmdt .: <br />'Aanspormr elgnalum (for exports orl <br />17. iransoodar AdmruwMmnn.w ...wN•...�_.__ .. Data leevlag NS.: <br />1B. Disarepatwy <br />the Doom ancytndlCation Space Qu <br />all <br />tab. Nlemile Facpdy(ar Gene wj <br />❑ Typa ❑ Road. ❑ Pal ReJocdon <br />I the manifest except as noted in Ilam 16a <br />Uey Year <br />FuSRBlecdon <br />I'. <br />GENERATOR'S Hill COPY <br />