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'Pliiase print or type.(Form designed for use on elite(12-pitch)typewriter, Form Approved,OMB No.2050-0039 <br /> UNIFORM HAZARDOUS 116 2-pagelof 3.Emergency Response Phone 4.Manh—st Tracking Number - <br /> WASTE MANIFEST r , 'G B F <br /> 0 2 6f)'3 7 5 5149--011 'D ""2 60 8 8 4 <br /> 5.Generators Name and Meiling Address Generatuft6goAddreag(r(hffelentUienralingaddress) - <br /> Fql�K.N,Ktls. <br /> 139naratorr.Phone: <br /> 0.Transporter I Company Name U.S. ber <br /> jjj�$.J�.0J�A <br /> Z IV4 <br /> K jjkV <br /> 7.TranWorfer 2 Company Name U.S.EPA ID Number <br /> B.Designated Facifty Name and Site Address U.S,EPA ID Number <br /> FC.fZi Rov�f!�4uq.$ <br /> 'W-00,1049, 104 <br /> .FadfiVe Phone: <br /> 08. 9K U.S.DOT DescilpWrl(lndUling Proper Shipping Name,Hazarx!Class,ID Number, 10.Containers 11.Tota' 12,Unit <br /> HM am Facking Group(it any)) 13.Waste Codea <br /> No. Type Quantity Wi.Nol. <br /> Z 2, <br /> LU <br /> 4, <br /> i. <br /> tons Additional In <br /> 15. GENP11ATCR'810IFFEROR'S CERTIFICATION; I hereby declare that the Contents of[his consignment are fully and=Uralaly descorbed above by N proper shipping name,and are classified,packaged;- <br /> marked and labeled/placarded,and are In all respects In proper condition Nr hnspVt according 10 aPPI100B international and MUM*GOVernmental regulajlons.If export$Npmenl and I am:the Primary'. <br /> Exparler,I Certify that the contents of this corwignment conform to tho terms of the attached EPAAckwMacigment of Consent, <br /> I certify[hat the WaSte.rnhmizalion statement Idainlifiad in 40 CFR 26227(a)Cif I am a large quantity generator)or(b)(ff I am a Voll quantity generator)is Inia, % <br /> Gen0ralue5f0iferors:PrintimIfTyped Name Si nature <br /> Month <br /> _j 16.Intematon-815hipments <br /> [:]),Pon to U.& EIE),Pn from u.s. Pori Of ehlrylexil: <br /> Trahsporle�siqnaitira(For exports cn4y): ()ala leaving U.S.: <br /> w17.Transporter AcknWedgmbnll of Receipt of Materials <br /> Trari§wrtorl RfibadfTyped Nan* <br /> Signature <br /> Month Day Year <br /> Transporter 2 Prkilew jym Neme <br /> Signature <br /> 18.Discrepancy I month Day Year <br /> 18a.Uscrepancy fndicaVon Space <br /> Quantity Type EIResidue EJ Partial Rejection El FLAI Rejection <br /> 18b-Alternate Facility or eneralor) <br /> U.S.EPA 10 Number <br /> Facility.Ph... <br /> 18r-$19118ture of Alternate Facility(or Generator <br /> hfanih Day Year <br /> .19.Hazardous file Report Management Method Codas(Le.,codes fcr h-srdW$Waste trQPVnent.disposal,and r0dycling systems) <br /> to I,. <br /> Q 2. 3. <br /> a- <br /> 20,basignaled Facility Owner or Operator:cortjficatOnuffecai.ptofhaZardc)uamatedafscovered by the msnjfastexcept aq noted in ii.m 18, <br /> rUMB01 I YPe0 Name ISigpalura <br /> Month Day Year <br /> EPA Form 8700-22(Rev 3-05) PfeViOUS editions are obsolete, j I <br /> SM 'S `des <br />