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Please print or type.(Form designed for use on a5le(12,pitch)typewriter.} Foim Approved,OMB No.2060-0039 <br /> t UNIFORM HAZARD[0)UjSj1.—C-nemlo(1105 Number 1.Page 1 If 3,Emergency ReSl)084 Phone 4.Manifest Tr dring Number <br /> WASTE MANIFEST Q I 1 -1 <br /> 5.Geaerafofs — 0009J12806 SKS <br /> -me ark Gencratu(z Site Address(if clifferent than mailing address) <br /> RX <br /> FIS S�:A <br /> r11K1','NF'44 CAM,, <br /> Genwatofs Phone: <br /> po.ttor I Company Name <br /> 'T— <br /> U,S,EPA ID Number <br /> 7,TranspodPr2C0fflpanyName U,S.EPA 10 Number <br /> Nesignatad Transporter <br /> and SgaAddrais <br /> U.S.EPA 10 Nurn* <br /> S- Poo SPIN PEE' <br /> 75-92a <br /> Facility's Phone: <br /> 9a, 9b.U.S.DOT Description(including Proper Stripping Nam,11228tit COW,11)Number, 10.Contak11.Total 12,Unit <br /> 'm <br /> HM and Packing Group Of any)) 1 13.Waste Code, <br /> PAI-;`47; ',1.ATjrF!AL,Ze, Oillaz. Na. Type Quantity WIJVOL <br /> ir! PIN <br /> LU <br /> ra <br /> 7. <br /> Lj <br /> 4. <br /> 14,rS�Pelclial Handling Inirtruttions and AddiiiDhai informstion <br /> 0, <br /> 3S rRjrF,5 4j$ <br /> IS, GENEPATOR'SIOPFEROR'SCERTIFICATIC)N:I hereby declare ft the writents of this oon*mont are my and accurately desca bed above by the proper shipping name,and are ciassifled,packaged, <br /> marked and JaWedlWacarded,and are in all respects in proper condition far transport aworclingle appr�oabla intomatiorelAnd national govemment*regulations.If export shipment and I am the Primary <br /> Exporter.I certify that the conlenta of this consignment omrorm to the terms of the attached EPA Ackn*adgment of Consent. <br /> I certify that the waste minfmizabon statement identifed In 40 CPR Z62.27(a)(Ef I am a large quant$y generator)Dr(b)Of I am a SM0qrility g to?))Sid' <br /> Generatoru-.— ua _ .!- ,-- I <br /> POntadnyped Name Signawro Month Day <br /> Year <br /> -+ -Tz�" <br /> i8:Intemaponal Shipments I�n-•t� <br /> 21 <br /> Expert from U.S. PDA of eruryld': <br /> Transporter signature(for axporlg only); <br /> QAte leaving U.S.: <br /> 17,TlrawortarAckwWedgmenl of RaceijA of Materials <br /> w Transporter Pr;nted/Typedl Nam t""L. Sigilaturg <br /> ticMonth Day Year <br /> ".IN <br /> raj <br /> Tt <br /> i.-C - m -A& n. <br /> r Prints ed Name <br /> Month Day Ylyir- <br /> 18.Diacrepancy <br /> 18a.Discrepancy IndicaVon Space EDTYP. E]Residu- 0 Pa dial Rejaaion ❑FuTl Rejeclion <br /> �8b'P&rnatv Fadity(or Generator) <br /> Manifest Reference Number: U.S.EPA ID Number <br /> 2 F..IiVs Phone: <br /> 1" <br /> 18 rllm-pan <br /> 18'.Discrepancy <br /> cy <br /> n-y' <br /> c <br /> 6_ <br /> b'nt'rnat I <br /> 0 Fal <br /> L <br /> Phone <br /> in I <br /> Uj 18C.Signature OfAllewte FaCilfly(of Generiito Mono Day Year <br /> 19.Hazardous Waste Report Management Method Codes(i.e..codes for hazardous waste treatment disposal,*nd recyeirig system) <br /> P 4.' 2. 3. 4. <br /> 20.Designated PadlitY Owner or Operator.CMfica(ion of reca; I of hazardous materials P covered by the manifest 6xceptaz Med in Hem 1 eo <br /> PrInteolITyped Name <br /> Month Day Year <br /> 22 2 ZI <br /> cnA r- <br /> 899--q TZO/Md OGZ—J, 9TG�98EKIS Dq:21 01 —8T-10 <br />