|
M � •
<br /> Please print cetype.(Form designed for use on offEq,,c-pitch)typewriter.) /3 Form Approved.OMB No.2050•GD39
<br /> UN1F HAZARDOUS 1,Generator IC Nurnb>u 2.Peg?1 dF31mergancy Response f�hone R.fAankest Ttacking Number �(W STE,AIAHIFE5T .v kin + )m it 69 '� 9 JJ a•
<br /> 8.GenenoWrs Name and A+falling Address Generator's Site Adcress(if dl than matting address)
<br /> ' u..1'N.t1MMWi i;kM1wT11tG,{It,' . ,�I✓�,,r•r,l
<br /> o:rj I imftl3 kti
<br /> •plt'rrgl � A *:?NIA GeneratoesPhone:f4 2 h,, ;+. .-;,
<br /> S.Trensporter t Company Neuse U.S.EPA ID Number
<br /> ,..fd IrWr„4nattVW;ur11A ' '444111,11 .'
<br /> 7,Transporter 2 Company Name U.S FPA ID Nambel
<br /> �1f it_tr �!,"€,' .,.t i' 'I ..I f i a ,f• r I A.. �'
<br /> 8.Designated Faddy Nam-and Site Addressx sill 1.OIikM y ��xnl wl�Iti�3Ml Jill J 5 I 11 C U.S.EPA ID Number
<br /> AAKt A000*1%GN Esarl Ph�Y_litl7;tph?'Ctf
<br /> ga, 9b.U.S,DOT Desoiption including Proper Shipping Name,Hazard Class,ID Number, 10.Contaners i 11.Tula) 12,Umt
<br /> W, and Pacl Group(8 any)', No. Type Quenbty V IA(ol 13.Waste Codes
<br /> t.l•Ik;tI,FR,•'�7.A ►if��1rC:+l,k+i:'ArJI���'�: 1lC:d.�lli{C.1Nyirlf�l+x�7 I:r1M
<br /> t rJ ,j30o
<br /> z 2,
<br /> w
<br /> qp
<br /> � a
<br /> a.
<br /> ,A.Spadal Handling tnsbudons andAddrtional Information
<br /> �`rFNa +f•'fr>�t!'f,tiur,al itfRiN!'r"CM+�E�:lr.�tfarnurrik.Wt�Ar►I+1Mli'11rq�
<br /> 30 k O !r ett'1
<br /> 15. GENERATOR'SIOPFEROR'S CERTIFICATION:I hereby declare that the cordents of Bi a consignment are fully and necurately described aboye by ihepgAt shipping name.and are dacsilod,pxkagad,
<br /> mashed and is l&diplautclod,and ase m.eu respects in prpar ocndniai for transport'aeoording to applicable intema6ggal and nabarrai govemrrw0'regul4c ns,I19xpert shpmem and;am the Pdmary
<br /> Exporter,I certify that the contents of ihls ctxurgnment caaform Oft terns of Sts aitached FPAA kr&mledgmsnl of Corso.
<br /> I ca ity that the waste mnimizalion slaiemanl identified to 4d CFR 2532 27(;)(t,I am a large quenlity 9eneraral or(b)(d I am a small quantity generator)is lruaa.
<br /> Ganr�raices(Ognrafs Pmrta�dffyped Name S{ wry" rf y f`s +��R a'R Goth Day Year
<br /> Tr+x� �'�` ..J` ` .�� Itfti..'"`"'^� l�'q.+•�.�Glil t t '''� ' �� � i � � �e;Y ���
<br /> zJ 16.1nlernatlatalSHpments
<br /> r- ❑Imporlto.U.S. ❑Ezpgr from U.S. Port of enlryletit
<br /> Z- Transportetegnature(torexporisonly'): Date lomirigU.S.;
<br /> 112� ITrranspmiarpcknowledgmantofRecelpfofMatermis
<br /> Tram r 1 Prime yped Name Signolure , -- ' ., Month Dov Year
<br /> z TranspoRer2PnrnedfTypedName; - Signoire '' �l Month Day Year
<br /> ! 18a.QWapmcyirrJrCalionSpace ❑ El Ic
<br /> I ❑Residue ❑Partial Ra'clan ❑Full Rejadim
<br /> Manifest Reference NumbeT,.
<br /> 18b Allemaie faality( U,S.EPA ID Natter
<br /> WW Woaildo alill
<br /> ZZ FaciliVs Phone: is
<br /> 18e.S'Snafure o`.A1Lrnate FBCllly(ti .neralor) Month Day Yaar
<br /> a
<br /> se19.Hazardgus MOD RbU4 Man'agaihant hledwd Codes{I.e.,codes fethxrardl waste ireakent,dl ant recycling systems)
<br /> 0 1. 2, 3. 4.
<br /> 20,Des€gmated Far,.Pily or or Operator;Certil of recall of hazardous materials covered by lire man€lost except as noted is)tern 103 `
<br /> PnnteMyped Name 5 nature,, r t, _ Month Day Year
<br /> EPA Form$7U0-22(Rev 3-05) Previous e'aitlons are obsolete. DESIGNATED FACWTV TO GENER,AT6R
<br /> AUG 0 6 2014
<br />
|