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plea"print or type.(Form desi rred for use on elite(12 pitch)typewder.) Farm Approved.OMB No.2050-gq 9 <br /> 4.Genarslnr ID Number .Fags i of g-Emergency Response Phone 4.Man[f 9t tplrrg NvrrRbet� �, <br /> UNIFORM HAZARD Us <br /> �" a y <br /> WASTE MANIFEST I-1,;Io l."I.E; :i J��i r. �_j i,)� «� �r•;;° <br /> 5.Gtsneraf0rs Name end Maiiirg Address Generators Site Address(if different than mailing address) <br /> D'f <br /> Generators Phone: U.S.EPA ID Number <br /> 6 TrFS rivf tRC;D{ 0(?jo <br /> U.S.EPA ID Number <br /> 7,Transporter 2 Company Name <br /> 8 DesignatedFacitiayName and Site Addtvae '#�... xCp, `ya{1 +�^� r }�'; j�}3 ; 1,� U.S.EPA ID Number <br /> wfijl <br /> y l�•�3*��,...�`i"�.of <br /> Facdil s Phone; <br /> 5a, <br /> 9b,1j,$.OOT aeaerip4on('mduding Proper Shipping Name,Hazard Class,1D.Numbei, t8.Containers 11.Told 12.Unit 13-Waste Codes <br /> HM arra Packing Group[f any)} No. Type Quantity W.Nof, <br /> 1UPSTE PAINS RELATE6 �ft�+Tt .�1alr� Ct�cAl�3�l�t�s� �y'J1�t� F��S`uI� ��t�;� <br /> a F0 TI, (ER13�1U) 7. 212 Ui"kf.1i`V051 F00310C'0S r• ilV 1.� YV.,.t� A�.�c� � <br /> LZ x ?ir<` iai; r�C'� : 3' 3 r`} �##'7af4:w.axr. d�?i,�. ,r••,y .t�i ..1�'t;� <br /> s, <br /> 4. <br /> 14.$pectalHandling lna6vchonaendAddilionallnformaUan <br /> LICENSEP SUR EQUENT BARRIERS AS NECESSARY <br /> 15. OENERATOR'S/oFFEROR"$CERTiFICATION' I hereby declare that ere contents of this consignment are fully and accuratetydescribed above by me proper shipping+lame,arid are class l ad packaged, <br /> marked and labefadlplacarded,and are in all respects it proper Condition for Uaospon according to aper aGle intemalonal and ratiom11 governments!regulations.If export shipment and I am the Primary <br /> Ezporier,I certify that the contents of this Consignment conform to the terms of the attached EPAAcknawledgment of Consent. <br /> I cortily thalthe waste mfnlmlzatior statement identified in 40 CS=R 262.27(a)(if I am a large quantity generator)of.(b)lift am a smaf OuanGOr generator)is true. <br /> GeneratagrOfferc sPrintadrfypedName <br /> nature <br /> Month pay-Year <br /> r <br /> j 16,iniemafional 5hipmwts <br /> ❑Import to U.S. ❑Export from t1S. Port of eptrylexit: <br /> 9 Transporter signature(for WOris Only): Date leaving US.: <br /> K 17,YrtnnsporterAdux ledgmenlnfReceiptofMaterials <br /> ITransporter 1 PrinEedfTyped Nameat Signs ray Monih Day Ysar <br /> !Wspwer 2 PrinledlTyped Name f!r Signature + Month Dey Year <br /> r <br /> 58.Discrepanq <br /> 18a.Discrepancy indlcalivn Space ElQuantify ❑Type ❑Residue ❑Pa tial Ref action L1 Full Rejection <br /> Manifest Reference Number: <br /> 186,Allomate Facility[or f3enerator} U.S.EPA ID Number <br /> ,a <br /> L) <br /> LL Fawrrty's Phone: Month Day Year <br /> 1 Bc.5ignatUte Of Altemi o FaUity(or Generator) <br /> d <br /> 1 S.Hazardous Wasle Report Management Method Codes(i e.,codes for hazardous waste veavneni,disposal,and recycling syMtoms) <br /> 21 <br /> 3. 4. <br /> 20.Designated Facility owner of Operator.Cer0flcatron of receipt of hazardous materials covered byihe manifest ei"tas acted in Item 180 Monih a y Year <br /> ad Name r: Sign u % +.',• <br /> If1� �3 rlr.. /Yj' J"1• '? 'f tf• �l- f���� /l ,t.,, +. ],i. . <br /> 899—d ZZ0/500d UZ—Z 9TGT798£916 fsaar�{—�a��>?s—Wfl�i3 6L ZL 01 ,-81—L0 <br />