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Jan 11 10 08: 37p • p. 2 <br /> Please print or type.(Form designed for use on elite(12-pitch)typewriter.) Form Approved,OMS No.2050-00 <br /> UMFORM HAZARDOUS I i te�rq Number 2.Page I of 3.Emergency Response Phone 4.Manifest Tracking Nmnbm <br /> WASTE MANIFEST `' .p�. �c (s-r -267 -o I-N 001519583 JJ K <br /> 1ra <br /> rator's Name and Miling Address Ge Iulrs SiteAddress(d different Than mailing address) <br /> qybaAhcne:tt� t 99F/I? 735' in_ .r7flbA�64 C?ao( <br /> 6.Transporter l Company Name •1 _ ,EPDNumber <br /> T Tininspapf 2Company Name U.S.EPAID Number <br /> 6. , ' Fad Name'and S. Add U.S.FPAIO Number <br /> s� iy, vie a7ss c 1 <br /> facility'sPhonw ,, .'� 3 gr—�7 if GAS oO/ <br /> 9a. gle.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, t0.Containers 11.70ta1 12.Unit <br /> and Pac* Group d - Quantity WtNol. 13.'Wasla Codes <br /> HM 9 DC(Karry)), No. Type y <br /> PONS j?ci-L4. /-6zir<a00_S was' if b" . <br /> D! put 5S G �L21 <br /> 2' 1✓�u- �Cn1• ({i(sctr ops twr�S 5fl� <br /> Dat 630s <br /> 3. <br /> 4, <br /> %Spedalli AIinglnet ' nsenaAdd Tonal m 171 �#3431 <br /> �- (pia4 4z mct�L <br /> Alarorbr44 f,pact Eoou fr�/, r Sr ' &RG f(( it.3 46( <br /> s�79 <br /> 15. GENERATOFIV&D"EROR'S CERTIFICATION: I hereby declare That the contents of this cwssignmsntarsfully and accurately described above by The propershlpplmg name,aha are classified,packaged, <br /> marked and tabeledblacarded,and aro In al respects in proper cundpion for transport according to applicable international and national governmental regulations.Nmrport shipment and I am the Primary <br /> Exporter.I cert"at the contents of this carmigNment conform tothe terms of Iheettadced EPAAckrlmNedgmenl of Consent <br /> I cartty,that the waste minimization statement Idendlled In 40 CFR 262-27(a)(If I am a large quantity generator)or(b)(if I oma small quanliy generator)Is True. <br /> Gene or Reroes PrintadR Name [� Signature Montt Day Year <br /> 4l� O arr elrl(J / /O <br /> 16.IntemaUonel Shipments <br /> ❑ImponW U.S. ❑F_Vrod from U.S. _ a f en0y1erit <br /> Transporter sgnahse(Mr eapons only); Date leaving U.S.: <br /> K 17.TrensparterAdmonviedgmem of Receipt of Meliorate <br /> Tmnsportor;l Pdnted(Typed Name Signature ! Manor yDyay Year <br /> OIL 10/ f <br /> F I <br /> Transporter 2 PAntedlfyped Name Signa Maim Day Year <br /> r- <br /> 16.Discrepancy_. <br /> 189.Discrepancy Indication Spam ty ❑Type ❑ftealdue ❑fardel Rsjecdm Full R11.11.❑ want <br /> Manifest Reference Number. <br /> ISb.A mmme Facility(nr Genemoo U.S.EPA ID Number <br /> J <br /> U <br /> s4s- Fadlitys phone: <br /> aw t6e Sgnaturs ofA temate Fedity(or Generator) Month Day year <br /> 2 <br /> 19.Hazardous Waste Report Management Method Codes(l.e.,codes for hazardous waste Immanent,disposal,and recycling systems) <br /> 2. 3.- 4. <br /> 20.Designated Facility Owner or Operator:Composition of receipt of hazardous materials covered by the manlfeal eacep as noted in Item 160 <br /> PnnteNTyped Nama Signature Month Day Year <br /> EPA Form OTOO-22(Rev.3-05) Previous editions are obsolete. DESIGNATED FACILITY TO DESTINATION STATE(IF REQUIRED <br />