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Please print or type.(Farm designed for use or elite(12-pilch ewriler) Form Approved.DMB No.2050-0039 <br /> Jop4 HA7ARi OUS 1,Generator ID Number 2.Psge f of 3.Emergancy Response Phone {.Manifest TraGking Number <br /> WASTE MAN)F ST ,,.�yL •`�s£ �' iJf1 d V■ S <br /> S.Generala's Name and MaN'%Address Generators Site Address(it different than mmlmg address) <br /> DELTA TRK OA�-Z5 TW; <br /> I(i412 --OUT}•j '"AD r"'('. BUI.), if1 °Y`;,Y•f?zJ ; <br /> Gen��eyyratp&s Phonepp: <br /> U.S.EPA 10 Number <br /> T Transporter 2 Ccmpany Name U.S.SPA ID Number <br /> B.Des gnaled Facility Name aril S teAddress >y Fur T Y^ (. �) 7 T 51 i fj( 1.n(r 15;j U.&EPA D Number <br /> 600'.) 38TH $TREET <br /> Faatilyfs Phone: <br /> ga. 8b.U.S-DDT Description gnctu tg Proper SHloping Name,Hazard Class,ID Number, 118,Containers 11-Tblal 12.Unit <br /> 13.Waste Codes <br /> HM and Puking Gacup(if shy)) No, TYP Quantity WtNol. <br /> dy ' tr,ASTF PAINT RFL fyTEQ riATERII L,^,3, 01263 ;rl'; F' F005 x'03 n001 <br /> 11.? M69128) 7, 24/OAL�F0MF003,DOO1, <br /> � z. <br /> 3, <br /> d. . <br /> 14,Special Handling lnstmcfiona and Additional lnfom abon 5K 1' °[')d O i;,,1 M;33-, (;M469;9 �–Ifz 06001M)730 O'N7 21 <br /> 15. GENERATOR'S10FFEROR'S CERTIFICATION:I hereby declare that the contents of this consignment are full and accurately desalted above by the proper shipping name•and are Gassi ted,pa&aged• <br /> marked and labeled/placarded,and are in all mspecrq in propel condition for transport amftfing to applkabla international and naGoral governmental regulOons.If export shipment and I am the Primary <br /> ExWaf,I cerfliy that the 0onlents of this con4nmerd conform to tha terms of the aNeched EPA Acknowledgment of Consent. <br /> t certify that the waste minimilaGan slatemant identified in 40 CFR 262.27(a)(f I am a large quantity genefalor)or(b)(if I am a small atranGly generator)is hue- <br /> Generatarslaferora PdntedfTyped Name Sfgnabxe, Month Day Year <br /> –4 16,Intemational Shtpmenl9 Import to U.S. I_f Expo!!from U.S- Pori of enlrylexiL'r" - <br /> Trsnsponer signature far exports only): Dale leaving U.S.: <br /> 17.TransparterAcknowledgment of Rsceipt of Materials <br /> Transporter1 PrinteNTyped Name Signaltffg� Month Day Year <br /> uj. � �'%! i,'� ''r� _ � r$�b .f.�.7,I'„I.i.. •��r nom,"r°- 5t �� � � �,>✓ yJ,,.i <br /> 7nsporter2 Printed Type Name Signature Month pay Year <br /> V, <br /> 18.Discrepancy <br /> 1 Ba.Discrepancy Indication Space ❑ Quanwy ❑Type ❑Residue ❑Padlal Rejection ❑Full Re)eM— <br /> Manifest Relerence Number; <br /> 18b.Alternate Facility(or Generalor) U,S,EPA ID Number <br /> J <br /> LL Facility's Phone: <br /> ►Li.r 1k..Signature of Altemate Facility(or General or) Month Day Year <br /> H <br /> 19.Hazardous waste Report Management Method Codes(iA.,codes for hazardous waste 1rea(maw,disposal,and recycling systems) <br /> p f. t„; t 2. <br /> A <br /> 2o.Designated Facility Omer or Operater.Certification of rewipt of hazardous materials covered by the manifest except as noted to item 183 <br /> Pri.1 dlType N mQ^ y Signalu f / Month Day Year <br /> EPA Farm 137t)f1-22 fRay.:i-flit Pravin„R�titrr„�s�+e�h�mca <br /> 899-3 TWWOd NZ-1, 91Gb9889Z6 fsaaT�{-l�a11�s-WO i3 81 Z OZ ,-BZ- 0 <br />