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Please print or type.(Form designed for use on elite(12-pitch)typewriter) <br /> 0 HAZARDOUS Form Approved.OMB No.205t]U039 <br /> IX IA�Dojjs 2.Page I of 3.Emergenq Response Phone 4,Man! CkIng Number <br /> A HAA""O'J' ""'e' <br /> WASTE M4NIIIFFST ?'Prio <br /> 77U8 S S <br /> 5.Gal "'Or"N"_and Mailing Address he" <br /> Ge <br /> m <br /> 'e, )teA if - Jing address} <br /> emlor's S �er".nt AM-11190WIM) <br /> Geri"oealfhone: <br /> 6.Transporter I Company Name <br /> T U-S.EPA JD Number <br /> 7.Transporter 2 Company Mame Y <br /> U.S.EPA 11)Number <br /> 8-Designated Fadlity Name and Silo Address L Cz N 1 F�t!5. U.S.EPA 10 Number <br /> 600f.� SUN <br /> FadltYsPhope' <br /> ga. 9b.U.S.DOT DewlpfiM(including Proper Shipping Namal,Hazard Glsss,iD Number, Conlaiflw <br /> HM and Packing Group(if Any)) 11.Total 12.UAll <br /> 13.Wada Codes <br /> No. Type uank /Vol-. <br /> 400-1 FOQ3 )00, <br /> Z 2. <br /> LLJ <br /> 0 <br /> Ci 4. <br /> 14.Special Handling InsWaions andAMMMI IrrIamabon <br /> 01'i 35r 3 2f 25 <br /> re fully"and im desenbed above by the proper ahop?rq rl�arno,and aro damff pa <br /> t <br /> iy 1 5 above� led okagW, <br /> marked and latoPledtplararded,and are in at reiPWG in peeper condition for trantpQrj aooffft to applicable ink-maliGnaland national govemnental reqUalorm.Ifexport shipm.entarg J=the Prima <br /> Exporter,I cenify that the contents of this consignmentconsignmentconformform to the terms Of the aftacwd EPA Ai;krqmedgment of Consent. ry' <br /> Icartifythat the waste rrhmi:Ution statenitt identified in 40 CPR 262,27(a)(if I am a large quanfily generator)or(b)(ffi am e smat 4uanlitygenerator)iskma- <br /> GenerVt0N0l%f&r`$PriMeRy"ped Name 81grinium <br /> Month Day Year <br /> 1 S.lAternationiV 5 <br /> Npiments Ij I.Pd to U.S. Evart from U.$. <br /> TransporterEighature(for exports only): Pod of entryle* <br /> �I� if �Acknavrledgmont ofReceipt of Materials <br /> Dille leaving U.S.: <br /> 7" <br /> 7 <br /> TM_aan-T;ja�W�rjk; iF(_edft)Qd Narng <br /> II.r *nth Day Year <br /> rh 1 1_ 7 F`ii7adf`rFd Name <br /> Day <br /> 18 Disappancy '' Mm Nj Y"r <br /> W Disc epancy Indication Space <br /> ciruantity Typo Q Residue El ParuiilRe*tion Q FuN RejecOw <br /> 18b.Ajlern@ te FaC41ity(or Generator) Manifest Reference Number. U.S.FFA ID Number <br /> Pacifit}fs Phone: <br /> Lu <br /> 19- Mmth �Y__Yeff <br /> -19,Hazardous Waste Report Management Method Codes(i.e..codes for haZWOM3 waste treatment,disposal.and recyc <br /> LU ling systems) <br /> 1. 2. " <br /> —- I – <br /> 20.DeRigristed Facxlfty Ovimer or OpArator Certification of_rem pl of hazardous materials covered by the nnan;Aagt except a.,notsd in Item 18a <br /> PrnlediTyped N 76. zgnature Month Day Year <br /> Si <br /> EPA Fnrm 97nf).99'/Pav.1-n.q1 PtAvWrR 04;11469 are nhen[.Ia <br /> 899-1 IZOIETod 06Z_I 9T6T79889T6 U92T�-A9172S-WCHE ZZ:Zj 0j,_8T_j0 <br />